The Effectiveness of Psychoanalytic Therapy: Evidence from ResearchPart 3: Dodo Redux
By Nancie Senet, Ph.D.
We last left our prescient bird knocked slightly off his perch. First the CBT group claimed that it simply wasn't true that "all had won and all must have prizes." They had proclaimed themselves to be the winners. And now Shedler had come along. At first our Dodo had been hopeful of retaining his "top bird" status when Shedler's meta-analysis of outcome research showed that CBT had not been the "winner" and that psychodynamic therapy had outcomes as successful as CBT. But before Dodo could reclaim his vaulted ranking among the scientifically inclined birds, he discovered that Shedler's further conclusions placed psychodynamic therapy a cut above the others. "Woe is me" thought Dodo, "I better just sit tight while the battle continues."
Indeed, it did continue. Many in the CBT community immediately took issue with Shedler’s findings. The following year the American Psychologist published in their February-March 2011 issue a series of commentaries critical of Shedler's analyses and conclusions. These writers (Anestis, Anestis, & Lilienfeld; McKay; Thombs, Jewett, & Bassel; Tryon & Tryon) based their criticisms of Shedler's work upon several rationales. It was argued that Shedler's meta-analysis provided no meaningful comparison of psychodynamic techniques to behavioral techniques for specific diagnosis. Therefore it had yielded no proof of psychodynamic efficacy. It was also argued that Shedler had based his meta-analysis on studies of poor quality. Acknowledging that there were factors common to many therapies, including psychodynamic and CBT, it was nevertheless, argued that these factors could not be claimed to be "psychodynamic factors." Tryon and Tryon argued, "Although these features may have originated in the psychodynamic literature, they transcended their origins and became pantheoretical more than 30 years ago." (p.151) Then with blatantly spurious reasoning, it was argued that the cornerstone of psychoanalytic concepts used for justification of psychodynamic therapies was the theory of "symptom substitution" and that there was no credible evidence supporting this assumption. They, therefore, concluded that no credible evidence existed to support the use of psychodynamic therapy.
Shedler refuted these arguments in that same American Psychologist issue. In his typically straightforward manner he laid out what he saw as their serious flaws. He argued that these writers were debunking fictions of their own inventions. “The academic psychology literature is filled with pronouncements about psychodynamic theory, often stated in authoritative tones, that present a picture of psychodynamic treatment that is unrecognizable to me and to other contemporary psychodynamic practitioners…the mental health professions have come to believe that these fictions, created as straw men by people who did not practice psychodynamic therapy, were psychodynamic therapy.” (p.152)
Shedler also argued that the accumulating evidence for the effectiveness of psychodynamic treatment has been repeatedly overlooked and that there existed a disingenuous double standard as to what constitutes research “evidence.” He reminded his critics that the more rigorously constructed studies showed no significant benefits for CBT.
Finally Shedler took up Tryon and Tryon’s contention that there were seven features that were not specifically psychodynamic, but simply common factors in effective psychotherapy. “The empirical research is unambiguous. It is not that some therapists trained in other approaches do not draw on some of these same features or that the features are incompatible with other therapy approaches. It is that psychodynamic therapists do these seven things more regularly, consistently, and deeply than practitioners of other forms of therapy. Moreover, psychodynamic theory and treatments models explicitly place these features at center stage, in ways that other approaches do not.” (p. 154)
It is those basic psychodynamic therapy features issuing from the body of psychoanalytic theory as a whole that are steadily accumulating research support, especially from neuroscience. In 1994 Alan Schore summarized the existing neuropsychological research that addressed the intertwinement of anatomical, physiological, and psychological growth in the infant. His view was that the infant’s unfolding physiological maturation in interaction with the salient environmental influences (primary object) created the ongoing architecture of the infant’s brain and “wired” the lifelong attachment patterns as well as modes of emotional regulation.
According to Schore (1991) “A developmental shift in the orbitofrontal cortex occurs at the end of the first year of human infancy…during this period, the infant is most sensitive to high intensity stimulation emanating from the mother’s emotionally expressive face. Maternal socioaffective stimulation induces heightened levels of arousal in the infant, and the resultant amplified levels of arousal act as a signal for the imprinting of new circuits in the orbitofrontal cortex.” (p.134) Then in the late practicing period the infant’s responses to maternal disapproval further the development of regulatory brain structures that function to modulate affect. Schore provided a brief description of these processes. “Incipient shame transactions in the late practicing period induce hormonal and neurohormonal alterations in the infant’s developing brain…The mother, the primary provider of affective socialization experiences to the child, thus directly influences the growth of prefrontal axons back down the neuraxis onto subcortical targets. These connections complete the organization of the lateral tegmental forebrain-midbrain limbic circuit…The hierarchical dominance of the frontolimbic cortex over this limbic circuit allows for the emergence of a number of adaptive functions…By the middle of the second year these neuropsychobiological advances enable the automodulation of hyperactive behaviors and hyperaroused states.” (p.230)
Through the continuing accumulation of neuropsychological research, the interconnections between physiological maturations and maternal ministrations and responsiveness that create the infant’s individual structure for cognitive, emotional and behavioral functioning has been established. Currently the work of the psychoanalytic researcher, Wilma Bucci, fits well with Shedler’s work on the common factors in psychotherapy. She has focused on the possible interface between underlying neuropsychological processes and the processes implicitly involved in psychotherapeutic change. She posits that a good therapeutic process enables a hyperarousal in the participants that activates existing psychological structures. Remember from the previously cited neuroscience research that these structures are ones that had been constructed during critical periods of infant development similarly through a hyperarousal produced in the interactions between mother and child. Those structures ideally evolve out of both loving as well as modulated disapproving emotional responses by the mother. When the preponderance of early exchanges with the child are instead negative, rageful, and/or abusive attacks, then the child develops a view of an unsafe world and learns patterns of response adaptive to those bad circumstances. As life proceeds, these patterns are prone to be clung to rigidly and are maladaptive to the maturing individual’s newer circumstances. Bucci proposes that effective psychotherapeutic intervention affects the underlying components of these patterns, especially the emotion schemas, in what she terms a “referential process.” In the interaction of the two participants emotion schema are activated mostly via emotional communication. A narrative process is established enabling the emotion schema to emerge in explicit and shareable symbolic forms. “Once the material is shared, and the affect is activated but sufficiently contained, there is opportunity for a phase of reorganizing...” (p. 19) Bucci writes that although psychotherapy approaches differ in the degree to which the exploration of the therapeutic relationship is used, the core of all psychotherapy is the dyadic interchange. A number of components operating in that interchange exist in all effective psychotherapy. The caveat though is that psychodynamic therapy places these factors at the heart of the work and uses them more than any other therapy, thus providing more of what helps.
"Okay. I'm a patient bird," thought Dodo. "I can wait this out and see what further conclusions come out of this research. At this point, I’m still half right. Although the CBTers think I’m all wrong. We’ll see about that."
Anestis, M., Anestis, J., & Lilienfeld, S. (2011). When it comes to evaluating psychodynamic therapy, the devil is in the details. American Psychologist, 66 (2), 149-151.
Bucci, W. (2012). The role of embodied communication in therapeutic change. In W. Tschacher & C. Bergomi (Eds.), The implications of embodiment: Cognition and communication. Exeter, U.K.: Imprint Academic. [Manuscript in preparation]
McKay, D. (2011). Methods and mechanisms in the efficacy of psychodynamic psychotherapy. American Psychologist, 66 (2), 147-148.
Shedler, J. (2011). Science or ideology? American Psychologist, 66 (2), 152-154.
Schore, A. (1994). Affect regulation and the origin of the self. Hillsdale, NJ: Lawrence Erlbaum.
Thombs, B, Jewett, L., & Bassel, M. (2011). Is there room for criticism of studies of psychodynamic psychotherapy? American Psychologist, 66 (2), 148-149.
Tryon, W. & Tryon, G.. (2011). No ownership of common factors. American Psychologist, 66 (2), 151-152.