May/June 2010 Issue

Reevaluating Psychodynamic Psychotherapy
By Christina Reardon
Social Work Today
Vol. 10 No. 3 P. 18

A recent study takes a new look at an “old” approach.

Many people have childhood memories of being teased by their peers for not wearing the most fashionable brand-name clothing and accessories. The children who wore the most expensive jeans and the flashiest tennis shoes considered themselves superior, even if these products were sometimes inferior to less glamorous options.

Jonathan Shedler, PhD, fears that a similar phenomenon is occurring within the world of mental health. And he wants it to stop.

Shedler, an associate professor of psychiatry at the University of Colorado School of Medicine, has recently attracted attention as the author of “The Efficacy of Psychodynamic Psychotherapy,” an article that appeared in the February-March issue of American Psychologist, the journal of the American Psychological Association. (A full-text version of the article is available at www.psychsystems.net/shedler.html.) In the article, Shedler argues that psychodynamic psychotherapy, with its focus on the client-therapist relationship, the exploration of a client’s emotional patterns, and the discussion of past experiences, is just as effective as—if not more effective than—other therapies that have been branded as superior.

Shedler says his goal is not to convince mental health professionals to throw out other therapeutic traditions in favor of psychodynamic approaches. Instead, he wants clinicians, researchers, and academics who may have snubbed psychodynamic psychotherapy as old-fashioned or ineffective to give it a second look.

“I think the public and mental health professionals are being sold a bill of goods about what good treatment is. I would like people to take seriously the larger truth that there is lasting value in self-reflection and self-knowledge,” he says. “The field has put far too much attention on giving therapies brand names. The brand name isn’t important. The therapist is what’s important and the relationship the therapist has with clients.”

Challenging Assumptions
In his article, Shedler reviews several meta-analyses of studies measuring the efficacy of psychodynamic therapy, other psychological treatments, and antidepressant medications. He draws conclusions about the meta-analyses by looking at the metric of effect size to compare treatments with one another or to control conditions. The larger the effect size, the more effective a treatment is considered to be.

The meta-analyses show that psychodynamic therapy results in significant effect sizes for clients with a variety of mental health difficulties and that these effect sizes often increase at long-term follow-up, according to Shedler. And the effect sizes for psychodynamic therapy are often larger than those for cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and antidepressants, he says.

Shedler acknowledges his research has limitations. For example, the number of randomized, controlled trials for CBT and other forms of psychotherapy is significantly larger than the number of such trials for psychodynamic therapy. And the scientific rigor of psychodynamic therapy studies has been sometimes lacking until recently.

Yet Shedler pulls no punches while discussing brand-name therapies he believes may be getting more credit and attention than they deserve. One of these therapies is DBT, which was developed by Marsha Linehan, PhD, of the University of Washington, more than 20 years ago to treat suicidal patients. DBT, which involves individual psychotherapy, group skills training, telephone consultation, and case consultation meetings for therapists, has become known worldwide as a treatment for borderline personality disorder as well as a variety of other problems, including eating disorders, substance abuse, anxiety, and posttraumatic stress disorder. Shedler says his research reveals that psychodynamic approaches have benefits for patients with personality disorders that equal or exceed the benefits of DBT.

“I’m not disparaging DBT, but it’s been oversold,” he says.

Such statements may make Shedler unpopular with critics of psychodynamic approaches, but he believes his article gives voice to clinicians who have long known that psychodynamic therapy works.

“I’m sure that there are going to be some commentaries that challenge [the article],” Shedler says. “But it has tapped into some strong feelings among the unheard majority.”

Shedler’s efforts to amass and present research data on psychodynamic therapy may give a new confidence to its supporters and may change attitudes among its critics, says Laura W. Groshong, LICSW, a Seattle-based psychotherapist.

“There has been too much demonization of treatments that we don’t personally use, and [psychodynamic therapy] is one of them. That needs to change,” Groshong says. “The article puts the psychodynamic view forward as a viable option.”

The article reminds social workers that the relationship between therapist and client can become a rich source of information that can be used to facilitate transformative change, says Charles A. Rizzuto, MSW, LICSW, an adjunct assistant professor in the MSW program at the Smith College School for Social Work in Northampton, MA.

“It’s about working with clients to offer them an individualized treatment rather than limiting oneself to one particular technique,” says Rizzuto, who also maintains a private practice in psychotherapy and supervision in Amherst and Holyoke, MA. “Manualized therapies often become rarified and people become rigid in promoting them. People start to think of them in the one-size-fits-all approach.”

Shedler’s work also challenges the assumption that the only way to measure whether a treatment is effective is to see how quickly it relieves symptoms, says Barbara L. Holzman, LCSW, ACSW, BCD, who is in private practice in Phoenix. The key to psychodynamic therapy’s long-term success is its recognition that relieving symptoms is only part of the process of promoting client well-being.

“In my experience, once you’ve established a therapeutic alliance with a client and they feel that you are listening to them and trust them, they can go deeper,” Holzman says. “They want symptom relief, but many also want to learn about the context that has led to their situation.”

Changing Attitudes
Although Shedler’s article may raise awareness of the benefits of psychodynamic therapy, its supporters know they face an uphill battle when it comes to changing long-held negative perceptions. Many people still associate psychodynamic therapy with Sigmund Freud, cartoon caricatures, lying on couches, boiling everything down to sex and aggression, and arrogant practitioners who work solely with the well-to-do.

Shedler acknowledges that many of these perceptions are rooted in historical realities.

“We psychodynamic people have done it to ourselves,” he says. “There was a time when psychodynamics was exclusive. There was an arrogance and a sense of authoritarianism. There was no effort to disseminate information; there wasn’t a culture to do that. There’s been a change in culture, but the perceptions remain.”

One factor that has significantly stymied acceptance of psychodynamic therapy is that the therapy’s earlier proponents shunned universities and instead chose to train practitioners in freestanding institutes, says Nancy McWilliams, PhD, a visiting full professor at Rutgers University’s Graduate School of Applied and Professional Psychology in Piscataway, NJ. That decision created resentment among university academics who, in turn, shunned psychodynamic therapies and supported other treatments. It also shielded proponents of psychodynamic therapy from having to defend their positions among people who disagreed with them, she says.

McWilliams, herself a proponent of psychodynamic therapy, says she doubts Shedler’s article will be enough to convince her colleagues in academics and academic research that the therapy is worth another look.

“It will be treated just as one person’s point of view,” she says. “I don’t see academics changing their religion on this.”

There are financial considerations as well. Researchers under pressure to show quick results tend to gravitate toward shorter-term therapies where they can show clear, measurable outcomes that help them attract additional research funds, McWilliams says. And managed care companies want to pay for as little treatment necessary to get results, says Donna M. Ulteig, MSSW, LCSW, ACSW, DCSW, partner in the private practice group Psychiatric Services, SC in Madison, WI.

“Third-party payers want measurable results, and it’s harder to show that with psychotherapy,” Ulteig says. “I don’t think that is necessarily bad, but we need to come up with better measures for the effectiveness of psychodynamic therapy. You can measure behavioral changes, but you can’t necessarily measure increased insight or understanding.”

The best hope for a change in attitudes may come from clients themselves. The public may have misperceptions about what psychodynamic therapy is or isn’t, but many clients intrinsically understand the importance of the self-knowledge and insight that psychodynamic therapy promotes, Ulteig says.

Groshong agrees that mental health consumers who are educated about the benefits of psychodynamic therapy could become powerful advocates for the approach.

“We, as therapists, can say it works all we want, but that doesn’t mean we can’t do a better job communicating with the public about what we do,” she says.

Promoting Tolerance
Shedler hopes his article serves as a rallying call for proponents of psychodynamic therapy who believe their approach has been shunned and misunderstood by the academic establishment, the insurance industry, and research communities.

“We’re supposedly having a dialogue in this country about mental health care, but it’s being dominated by pharmaceutical companies and health insurers,” Shedler says. “The people we’re not hearing from are the practitioners who are treating the clients and the clients themselves.”

But supporters of psychodynamic therapy risk repeating past mistakes if they believe their approach is the only valid one, Holzman says. An eclectic approach that takes elements from various traditions is the best way to ensure treatment meets each client’s individual needs, she says.

Shedler’s own research shows that many clinicians are using such eclectic approaches, even if they don’t know it. In his article, he reviews studies showing that many therapists who believe they are using CBT integrate many aspects of psychodynamic therapy into their work.

Social workers and other mental health professionals must continually remind themselves that clients may not always want the approach therapists think is best, Groshong says. That open-mindedness also is needed among therapists with different schools of thought, she says.

“We need to have more tolerance. It’s quite striking to me that a field that promotes tolerance can be very intolerant about different points of view about how to do therapy,” Groshong says. “We, psychodynamic people as a group, need to be more willing to listen to how other therapists help their clients and be open to the idea that our methods might not be the best for everyone. Our respect for others is missing and others’ respect for us is missing.”

— Christina Reardon is a freelance writer based in Harrisburg, PA, and an MSW candidate at Temple University.

Characteristics of Psychodynamic Therapy
Much confusion remains, especially among members of the public, about the topic of psychodynamic therapy. In a recent article published in American Psychologist, Mark J. Hilsenroth, PhD, and Matthew D. Blagys, MA, explore what distinguishes psychodynamic approaches from other therapies such as cognitive behavioral therapy. They identify these seven core characteristics of psychodynamic process and technique:

• Focus on affect and expression of emotion: The therapist helps the client identify and discuss a full range of feelings, including those that may be contradictory or distressing. There also is the recognition by the therapist and the client that intellectual insight and emotional insight are not the same.

• Exploration of attempts to avoid distressing thoughts and feelings: The therapist focuses on and explores the client’s attempts to avoid troubling aspects of an experience. These attempts, made knowingly and unknowingly, can range from being late for appointments to changing the subject when distressing issues are raised.

• Identification of recurring themes and patterns: The therapist works with the client to identify recurring patterns in thoughts, feelings, relationships, and experience. A client may or may not be aware of these patterns prior to therapy.

• Discussion of past experience: Psychodynamic therapy recognizes that past experiences, particularly early experiences with attachment figures, shape the experience of the client in the present.

• Focus on interpersonal relations: Psychodynamic therapy explores how adaptive and nonadaptive aspects of personality and self-concept are created by and reflected in interpersonal relationships.

• Focus on the therapy relationship: The therapist-client relationship provides information about the interpersonal patterns the client has established in the past. The client’s view of the therapist often will be shaped by past experience with other relationships, so the therapist-client relationship can be a vehicle for client change.

• Exploration of fantasy life: The therapist encourages the client to talk openly about fantasies, desires, fears, dreams, and daydreams. This exploration provides both parties with valuable insight about how the client views self and others.

— CR