Long-Term Psychoanalysis Works, Study Finds

But many psychiatrists remain skeptical that treatment is being properly applied

by Aalok Mehta

November 7, 2008

Summary: A detailed analysis has found that long-term psychodynamic psychotherapy works better for many patients than short-term therapy, in the latest round of the debate over how best to treat people who have mental disorders.

The latest volley in the long-running debate over psychoanalysis has come down in favor of the controversial technique.

Scientists in Germany who analyzed more than 20 studies of long-term psychodynamic psychotherapy (LTPP) found that the treatment is more helpful and cost-effective than shorter rounds of therapy for people who have complex mental disorders.

The long-term therapy, an updated version of Sigmund Freud’s trademark psychoanalysis, revolves around addressing unconscious conflicts in patients, many believed to stem from childhood, through the patient-therapist bond. Many psychiatrists prefer less-open-ended treatments, however, citing a dearth of scientific research that shows whether the long-term therapy works.

“But this is a landmark study,” says Glen Gabbard, a professor of psychoanalysis at Baylor College of Medicine. Long-term psychodynamic psychotherapy has suffered from an “unfair stereotype” of not being empirically validated, he added, but “this study will help legitimize LTPP as a reasonable, cost-effective treatment for many psychiatric patients.”

Critics respond that the study, though promising, doesn’t address deeper issues, such as whether LTPP is more effective than other forms of long-term treatment and whether such intrusive means are recommended more often than is necessary.

Hundreds of patients

For their meta-analysis, Falk Leichsenring, a professor of psychosomatics and psychotherapy at the University of Giessen, and Sven Rabung, a professor of medical psychology at University Medical Center Hamburg-Eppendorf, compiled results from 23 studies. In total, these assessed more than 1,000 patients who had undergone LTPP, which is defined as at least 50 sessions or more than a year of treatment.

“LTPP was significantly superior to shorter forms of psychotherapy applied in the control groups,” not only in overall effectiveness but also in addressing specific mental problems and in treating personality issues such as avoidant and obsessive-compulsive personality disorders, Leichsenring wrote via e-mail. In addition, the more treatment the patients received, the better they tended to do.

The researchers then looked at how well long-term psychodynamic psychotherapy worked individually for patients with chronic mental disorders, multiple mental disorders or complex depressive and anxiety disorders. For all those conditions, “LTPP showed significant, large and stable treatment effects, which even significantly increased between end of treatment and follow-up assessment,” Leichsenring wrote.

The researchers argue that the results are clear: LTPP is something all psychiatrists should consider when treating patients with complicated mental disorders.

Controversy continues

The results are not completely unexpected: Most psychiatrists acknowledge that long-term psychodynamic psychotherapy can be helpful for certain patients and may even be the only good treatment in severe cases.

“My impression is that the statistical findings obtained in [long-term] psychotherapy research are as robust as in any health science field,” says Jeffrey Binder, a professor at the Georgia School of Professional Psychology.

But new research is unlikely to settle the contentious debate over how best to treat psychiatric patients.

For one, the meta-analysis may be comparing apples and oranges by including studies with different research goals, ways of measuring progress and even ways of conducting LTPP, given the many refinements to the treatment made during the past few decades, Binder says.

The findings also didn’t compare LTPP to other long-term psychotherapies to find out which is the most effective, points out Nicholas Cummings, a distinguished professor at the University of Nevada, Reno, and a past president of the American Psychological Association. And the results of the research may exacerbate LTPP being prescribed too often by proponents who see it as a default treatment instead of something of a last resort.

“I have no quarrel with the assertion that LTPP is effective,” Cummings said. “But we should only provide it when it’s necessary—not as a frill.

“This kind of intensive looking into childhood is not necessary in most cases,” he added. “And often, it mucks up the works,” by prolonging treatment or reinforcing narcissistic behavior, for example.