Johathan Shedler

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The Efficacy of Psychodynamic Psychotherapy

Jonathan Shedler
University of Colorado Denver School of Medicine

February–March 2010 American Psychologist
© 2010 American Psychological Association 0003-066X/10/$12.00
Vol. 65, No. 2, 98–109 DOI: 10.1037/a0018378

The Flight of the Dodo

The heading of this section is an allusion to what has come to be known in the psychotherapy research literature as the Dodo bird verdict. After reviewing the psychotherapy outcome literatures of the time, Rosenzweig (1936), and subsequently Luborsky, Singer, and Luborsky (1975), reached the conclusion of the Dodo bird in Alice in Wonderland: “Everybody has won, and all must have prizes.” Outcomes for different therapies were surprisingly equivalent, and no form of psychotherapy proved superior to any other. In the rare instances when studies found differences between active treatments, the findings virtually always favored the preferred treatment of the investigators (the investigator allegiance effect; Luborsky et al., 1999).

Subsequent research has done little to alter the Dodo bird verdict (Lambert & Ogles, 2004; Wampold, Minami, Baskin, & Callen Tierney, 2002). For example, studies that have directly compared CBT with short-term psychodynamic therapy for depression have failed to show greater efficacy for CBT over psychodynamic therapy or vice versa (Cuijpers et al., 2008; Leichsenring, 2001). Leichsenring (2001) noted that both treatments appeared to qualify as empirically supported therapies according to the criteria specified by the American Psychological Association’s Division 12 Task Force on Promotion and Dissemination of Psychological Procedures (1995; Chambless et al., 1998). Some of the studies compared psychodynamic treatments of only eight sessions’ duration, which most practitioners would consider inadequate, with 16-session CBT treatments. Even in these studies, outcomes were comparable (Barkham et al., 1996; Shapiro et al., 1994).

There are many reasons why outcome studies may fail to show differences between treatments even if important differences really exist. Others have discussed the limitations and unexamined assumptions of current research methods (Goldfried & Wolfe, 1996; Norcross, Beutler, & Levant, 2005; Westen et al., 2004). Here I focus on one salient limitation: the mismatch between what psychodynamic therapy aims to accomplish and what outcome studies typically measure.

As noted earlier, the goals of psychodynamic therapy include, but extend beyond, alleviation of acute symptoms. Psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility. Symptom-oriented outcome measures commonly used in outcome studies (e.g., the Beck Depression Inventory [Beck, Ward, Mendelson, Mock, & Erbaugh, 1961] or the Hamilton Rating Scale for Depression [Hamilton, 1960]) do not attempt to assess such inner capacities (Blatt & Auerbach, 2003; Kazdin, 2008). Possibly, the Dodo bird verdict reflects a failure of researchers, psychodynamic and nonpsychodynamic alike, to adequately assess the range of phenomena that can change in psychotherapy.

The Shedler–Westen Assessment Procedure (SWAP; Shedler & Westen, 2007; Westen & Shedler, 1999a, 1999b) represents one method of assessing the kinds of inner capacities and resources that psychotherapy may develop. The SWAP is a clinician-report (not-self report) instrument that assesses a broad range of personality processes, both healthy and pathological. The instrument can be scored by clinicians of any theoretical orientation and has demonstrated high reliability and validity relative to a wide range of criterion measures (Shedler & Westen, 2007; Westen & Shedler, 2007). The SWAP includes an empirically derived Healthy Functioning Index comprising the items listed in Table 2, which define and operationalize mental health as consensually understood by clinical practitioners across theoretical orientations (Westen & Shedler, 1999a, 1999b). Many forms of treatment, including medications, may be effective in alleviating acute psychiatric symptoms, at least in the short run. However, not all therapies aim at changing underlying psychological processes such as those assessed by the SWAP. (A working version of the SWAP, which generates and graphs T scores for a wide range of personality traits and disorders, can be previewed at www.SWAPassessment.org.)

Researchers, including psychodynamically oriented researchers, have yet to conduct compelling outcome studies that assess changes in inner capacities and resources, but two studies raise intriguing possibilities and suggest directions for future research. One is a single case study of a woman diagnosed with borderline personality disorder who was assessed with the SWAP by independent assessors (not the treating clinician) at the beginning of treatment and again after two years of psychodynamic therapy (Lingiardi, Shedler, & Gazzillo, 2006). In addition to meaningful decreases in SWAP scales that measure psychopathology, the patient’s SWAP scores showed an increased capacity for empathy and greater sensitivity to others’ needs and feelings; increased ability to recognize alternative viewpoints, even when emotions ran high; increased ability to comfort and soothe herself; increased recognition and awareness of the consequences of her actions; increased ability to express herself verbally; more accurate and balanced perceptions of people and situations; a greater capacity to appreciate humor; and, perhaps most important, she had come to terms with painful past experiences and had found meaning in them and grown from them. The patient’s score on the SWAP Healthy Functioning Index increased by approximately two standard deviations over the course of treatment.

A second study used the SWAP to compare 26 patients beginning psychoanalysis with 26 patients completing psychoanalysis (Cogan & Porcerelli, 2005). The latter group not only had significantly lower scores for SWAP items assessing depression, anxiety, guilt, shame, feelings of inadequacy, and fears of rejection but significantly higher scores for SWAP items assessing inner strengths and capacities (see Table 2). These included greater satisfaction in pursuing long-term goals, enjoyment of challenges and pleasure in accomplishments, ability to utilize talents and abilities, contentment in life’s activities, empathy for others, interpersonal assertiveness and effectiveness, ability to hear and benefit from emotionally threatening information, and resolution of past painful experiences. For the group completing psychoanalysis, the mean score on the SWAP Healthy Functioning Index was one standard deviation higher.

Table 2
Definition of Mental Health: Items From the Shedler– Westen Assessment Procedure (SWAP–200; Shedler& Westen, 2007)

  • Is able to use his/her talents, abilities, and energy effectively and productively.
  • Enjoys challenges; takes pleasure in accomplishing things.
  • Is capable of sustaining a meaningful love relationship characterized by genuine intimacy and caring.
  • Finds meaning in belonging and contributing to a larger community (e.g., organization, church, neighborhood).
  • Is able to find meaning and fulfillment in guiding, mentoring, or nurturing others.
  • Is empathic; is sensitive and responsive to other people’s needs and feelings.
  • Is able to assert him/herself effectively and appropriately when necessary.
  • Appreciates and responds to humor.
  • Is capable of hearing information that is emotionally threatening (i.e., that challenges cherished beliefs, perceptions, and self-perceptions) and can use and benefit from it.
  • Appears to have come to terms with painful experiences from the past; has found meaning in and grown from such experiences.
  • Is articulate; can express self well in words.
  • Has an active and satisfying sex life.
  • Appears comfortable and at ease in social situations.
  • Generally finds contentment and happiness in life’s activities.
  • Tends to express affect appropriate in quality and intensity to the situation at hand.
  • Has the capacity to recognize alternative viewpoints, even in matters that stir up strong feelings.
  • Has moral and ethical standards and strives to live up to them.
  • Is creative; is able to see things or approach problems in novel ways.
  • Tends to be conscientious and responsible.
  • Tends to be energetic and outgoing.
  • Is psychologically insightful; is able to understand self and others in subtle and sophisticated ways.
  • Is able to find meaning and satisfaction in the pursuit of long-term goals and ambitions.
  • Is able to form close and lasting friendships characterized by mutual support and sharing of experiences.

Methodological limitations preclude drawing causal conclusions from these studies, but they suggest that psychodynamic therapy may not only alleviate symptoms but also develop inner capacities and resources that allow a richer and more fulfilling life. Measures such as the SWAP could be incorporated in future randomized controlled trials, scored by independent assessors blind to treatment condition, and used to assess such outcomes. Whether or not all forms of therapy aim for such outcomes, or researchers study them, they are clearly the outcomes desired by many people who seek psychotherapy. Perhaps this is why psychotherapists, irrespective of their own theoretical orientations, tend to choose psychodynamic psychotherapy for themselves (Norcross, 2005).