Psychodynamic Research
Prof. Dr. Falk Leichsenring, University of Giessen, Department of Psychosomatics and
Psychotherapy, Giessen, Germany and University of Rostock, Department of
Psychosomatics and Psychotherapy, Germany
b Prof. Dr. Allan Abbass, Dalhousie University, Halifax, Canada
c Prof. Dr. Peter Fonagy, Research Department of Clinical, Educational and Health
Psychology, University College London, London, United Kingdom
d Prof. Dr. Kenneth N. Levy, Pennsylvania State University, College of the Liberal Arts,
USA
e Prof. Dr. Peter Lilliengren, Department of Psychology, University of Stockholm, Sweden
f Prof. Dr. Patrick Luyten, Faculty of Psychology and Educational Sciences, University of
Leuven, Leuven, Belgium and Research Department of Clinical, Educational and Health
Psychology, University College London, London, United Kingdom
g Prof. Dr. Nick Midgely, University College London, London, UK
h Prof. Barbara Milrod, Albert Einstein College of Medicine, New York, USA
i Prof. Dr. Christiane Steinert, International Psychoanalytic University, Berlin, Germany and
University of Giessen.
The World Health Organization (WHO) recently issued updated guidelines for treating mental health conditions, emphasizing evidence-based manual-guided psychotherapeutic treatments.1 We applaud the WHO's effort to broaden access to evidence-based psychotherapy. Yet, we are concerned that the recommendations predominantly endorse behavior therapy (BT) and cognitive-behavior therapy (CBT) techniques, for both adults and young people. This selection overlooks the significant evidence supporting other therapeutic approaches, including but not limited to psychodynamic therapy, except for a brief acknowledgment of its use in treating depression.
The WHO claims to base recommendations on empirical evidence 1,2, which however, contrast with the omission of robust support for other therapeutic methods such as psychodynamic therapy. Recent high-quality research reviews, which have been published in high-ranking and leading scientific journals3, have demonstrated that manual-guided psychodynamic therapy meets the updated American Psychological Association's criteria for empirically supported treatments 4, based on several comprehensive meta-analyses. 5-9 This endorsement covers the psychodynamic treatment of depressive, anxiety, somatoform, and personality disorders, with clinically meaningful effects over controls and no meaningful differences in efficacy compared to other evidence-based treatments.3 The quality (certainty) of evidence was at least moderate for the primary outcomes, that is comparable to that of the evidence on which the WHO based their recommendations, for example, for depressive disorders, anxiety disorders, or self-harm and suicide.2, p. XVIII-XXX In addition, favorable data were reported for psychodynamic therapy on the stability of effects in follow-ups, on the balance between desirable and undesired effects, on cost-effectiveness, on effectiveness under real-word conditions, on the generalizability of effects across diverse patient populations as well as on mechanisms of change.3 Furthermore, for improving functioning superiority over controls and no differences to other empirically supported treatments were found in these conditions. 3 In contrast, the WHO found that (for psychotherapy of depression) none of the studies included by the WHO reported improvements in quality of life and functioning. 2, p. 61 In line with American Psychological Association's criteria for evidence-based treatments, the substantial body of evidence for psychodynamic therapy was shown to warrant a strong recommendation of psychodynamic therapy in the conditions listed above.3 The review by Leichsenring et al. 3 was published in 2023, maybe this is why it has not been taken into account by the WHO in 20232, but it could have been included in the WHO 2024 publication.1
Further evidence for psychodynamic therapy exists. For the treatment of chronic pain a meta-analysis even suggests that short-term psychodynamic therapy may even be superior to CBT 10, with further studies needed to confirm the results. Furthermore, several randomized controlled studies have shown the efficacy of psychodynamic treatments for patients unresponsive to other treatments, including those suffering from treatment-resistant or chronic depressive 11-14 or somatoform disorders. 15-19 In depression with comorbid personality disorders a recent RCT found psychodynamic therapy as efficacious as schema therapy, with longer-term treatments of schema therapy and psychodynamic therapy being superior to short-term treatments.20 This is consistent with a meta-analysis testing equivalence of psychodynamic therapy to other evidence-based treatments which found psychodynamic therapy to be as efficacious as other evidence-based therapies.21 In addition, there is evidence from multiple randomized controlled trials and a meta-analysis that psychodynamic therapy is efficacious in reducing suicide attempts and self-harm in both adults and adolescents 22-24, as well as in the context of personality disorders 3,5,8 - repeated self-harm and suicide attempts rarely occur isolated but usually in the context of severe personality disorders. 25,26 For psychotherapy of self-harm and suicidality, however, the WHO recommended only digital stand-alone methods based on CBT, dialectical behaviour therapy (DBT), problem-solving therapy (PST) and mindfulness, with only a conditional recommendation based on low certainty of evidence.1 In addition, further evidence for psychodynamic therapy is available for the treatment of eating disorders, substance-related disorders (opiate addiction), and for the application of internet-delivered psychodynamic therapy for various conditions. 27-33. Furthermore, evidence is available for the treatment of children and adolescents with depression 34, as demonstrated by the inclusion of psychodynamic psychotherapy in UK guidelines on childhood depression developed by the National Institute for Health and Care Excellence. Evidence for psychodynamic therapy of post-traumatic stress disorder (PTSD) comes from randomized controlled trials 35,36 and quasi-experimental studies 37,38, but also from studies on patients with severe personality disorders such as borderline personality disorder who typically show a high prevalence of traumatic experiences.25,26 In addition, there are several ongoing large-scale multi-center studies of psychodynamic therapy in complex PTSD 39-45 whose results need to be taken into account after their publication.
The finding of no clinically significant differences in efficacy between psychodynamic therapy and other evidence-based treatments such as CBT are consistent with reviews by non-psychodynamic researchers, for example, in depressive disorders, personality disorders or other mental disorders, showing that these findings cannot be attributed to a possible researcher allegiance of psychodynamic researchers.46,47, p. 64,48
Of note, evidence shows that behavior therapy and cognitive-behavior therapy cannot be viewed as the sole solutions for mental health care. A rigorous independent analysis of studies listed in the American Psychological Association’s database for empirically supported treatments (ESTs) revealed that the replicability and power estimates of many ESTs, including multiple BT/CBT methods like DBT, were found to be low. 49 Some treatments that were considered to have “strong” evidence did not show superior efficacy compared to those deemed to have “modest” evidence. 49 According to these results, several methods of BT or CBT have weaker evidence than previously assumed. In addition, a meta-analysis on depressive and anxiety disorders reported that the effects of CBT in depressive and anxiety disorders are uncertain and should be considered with caution due to the small number of high-quality studies.50 Furthermore, the success rates for BT/CBT in depressive and anxiety disorders in terms of response hover around 50%, with remission rates being notably lower.
51-54 This applies to CBT of PTSD as well. Roughly half to two-thirds of study participants retain their PTSD diagnosis. 55-59 Reviews of the three STRONG STAR military PTSD trials 60 found overall only 31% of patients recovered or improved. Among VA patients identified as “suitable” for prolonged exposure and Cognitive Processing Therapy, 38.5% of Veterans who initiated treatment dropped out. 61 One likely factor in this high attrition is that many patients cannot tolerate the demands of exposure-based treatments. 62 Evidence is growing that non-exposure-based approaches may be just as effective as exposure-based approaches 58,63, all of which was ignored by the WHO recommendations.
These data underscore that no single psychotherapy approach can currently be regarded as the definitive solution for all patients.64 A significant number of patients who do not respond to BT/CBT may benefit from alternative evidence-based psychotherapeutic approaches. Our concern is heightened by the WHO’s recommendation of primarily a singular psychotherapy approach 1,2, potentially leaving many patients without access to more suitable treatments that could offer them substantial benefits. For anxiety disorders, for example, the WHO noted that there were limited data for psychotherapeutic interventions other than those based on CBT and that further research is needed to clarify if other therapies can offer similar benefit. 2, p. 20 Here, we provide such evidence for psychodynamic therapy, not only for anxiety disorders but also for various other mental disorders.3,27,33
With regard to implementation, there is evidence that psychodynamic therapies are adaptable and can be effectively taught to new practitioners from diverse theoretical and professional backgrounds. 65-68 While the efficacy and the long-term benefits of long-term psychodynamic therapy in complex and treatment resistant mental disorders has been demonstrated 11,69,70, substantial evidence also points to the broad applicability and efficacy of short-term psychodynamic methods. 3,5-10 In addition, psychodynamic therapies can be delivered in guided and online formats, digitally supported, making them accessible and distributable on a wide scale. 27-33
For these reasons, we advocate for the incorporation of psychodynamic therapies among other evidence-based psychotherapeutic approaches by the WHO as well as for the involvement of experts in the WHO guideline development group with current knowledge on the outcomes of other approaches such as psychodynamic or interpersonal therapy. This procedure implies a form of adversarial collaboration.71 and may help to avoid biased recommendations 49,72,73, This proposal is consistent with recommendations for advancing guideline development in health care.74 Although there is evidence that reporting quality of WHO guidelines has generally improved over the years, it can be further improved in a number of areas.75
By embracing a broader array of empirically supported therapeutic methods, the goal is to elevate the overall quality and efficacy of global mental health care.
This appeal is supported by more than 200 researchers from all around the world, including the Chair of the International Psychoanalytic Association Research Committee and the president of the American Board and Academy of Psychoanalytic and Dr. Birgit Jänchen van der Hoofd, president of the German Society for Psychoanalysis, Psychotherapy, Psychosomatics and Depth (DGPT).
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