Harvard Mental Health Letter

Commentary: The value of long-term psychodynamic psychotherapy


The value of long-term psychodynamic psychotherapy

Long-term psychodynamic psychotherapy, which helps patients understand causes of psychological distress that would otherwise remain outside their awareness, has long been under siege from third-party payers. That it survives at all may be a tribute to its value, but the evidence supporting its effectiveness has been so thin that — as a treatment — it has been more often tolerated than appreciated by those who bear its cost.

But in October 2008, the Journal of the American Medical Association published a first-of-its-kind meta-analysis that demonstrated the value of this treatment, especially for patients with complex mental disorders, such as personality disorders and difficult-to-treat anxiety and mood disorders. The authors reviewed 23 studies of traditional psychodynamic psychotherapy where treatments lasted at least one year or 50 sessions. About half were randomized controlled trials; the rest were observational trials that did not compare patient outcomes with those of a control group. Together, the studies enrolled just over 1,000 patients.

The researchers dealt forthrightly with a paradox that dogs this research. Randomized controlled trials are the highest standard of evidence, but psychodynamic therapy conducted under controlled conditions is unlike what is practiced in the average therapist's office. Observational studies do provide a realistic view of psychotherapy practice, but they do not control for the individual variations (such as age, sex, and life experience) that can affect outcomes.

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