Psychodynamic Research
Process Research in Psychodynamic Therapy in Adults
While outcome research is about establishing if therapy leads to improvement or not, process research is about establishing how therapy leads to improvement. In practice, this entails linking therapist interventions with mechanisms of change, and in turn linking mechanisms to therapy outcome. Few studies of any therapy approach have provided convincing evidence of the whole chain from therapy interventions through mechanisms of change to outcome (Kazdin, 2007, Kazdin, 2009). Instead, researchers usually focus on one part of the sequence, either linking interventions to mechanisms, or linking mechanisms to outcome (Falkenström, Solomonov, & Rubel, submitted). Therapy interventions can be studied using dismantling RCTs, although such studies are rare and come with several problems (e.g. Bell et al., 2013), meaning that in practice most studies are observational. For studies linking mechanisms to outcome, it is even more difficult to conduct RCTs, since most mechanisms are not amenable to direct experimental manipulation. Thus, most research is observational, meaning that other variables than the ones studied may influence the findings. However, there is intensive methods development in this area, and many studies today are much stronger for causal inference than simple correlational studies (Falkenstrom et al., 2017, Zilcha-Mano and Webb, 2020). In the following, we first list evidence linking mechanisms to outcome, and then evidence linking interventions to mechanisms:
In psychodynamic therapy there is evidence for mechanisms of change from
reviews (Crits-Christoph and Connolly Gibbons, 2021, Jennissen et al., 2021, Leichsenring et al., 2023)
meta-analyses (Fluckiger et al., 2018, Fluckiger et al., 2020, Jennissen et al., 2021)
providing evidence linking mechanisms to outcome for
therapeutic alliance (Crits-Christoph and Connolly Gibbons, 2021, Fluckiger et al., 2018, Fluckiger et al., 2020, Zilcha-Mano et al., 2015)
insight (Gibbons et al., 2009, Hoglend and Hagtvet, 2019, Jennissen et al., 2021, Kallestad et al., 2010)
reflective functioning (De Meulemeester et al., 2018, Halstensen et al., 2021)
defense mechanisms (Bond and Perry, 2004, Perry and Bond, 2012)
emotion processing (Fisher et al., 2020, Hoglend and Hagtvet, 2019)
rupture and repair (Eubanks et al., 2018)
There is also evidence for linking psychodynamic interventions directly with outcome from
reviews (Crits-Christoph and Connolly Gibbons, 2021, Crits-Christoph et al., 2013) and individual studies (see below)
providing evidence for
psychodynamic technique in general outcome (Barber et al., 1996, McCarthy et al., 2016)
interpretations (Keefe et al., 2019, Zilcha-Mano et al., 2023)
transference interpretations (Crits-Christoph et al., 2013, Hoglend et al., 2006)
The research linking interventions to change in mechanisms is sparser, although Crits-Christoph and Connolly Gibbons (2021) report some evidence linking PDT to improvement in insight, and some (but more limited) evidence linking PDT to improvements in reflective functioning and defenses.
Open questions:
Causal effects
As mentioned, establishing cause and effect relationships is more challenging in process research than in outcome research. This is not specific to PDT but applies to all psychotherapy orientations. Intensive methods development is being conducted to improve causal inference from observational research, some of which is summarized in a recent special section of the journal Psychotherapy Research (Falkenström, 2023).
Effects of interventions on mechanisms
As noted above, the evidence linking interventions to change in mechanisms is sparse. The research that exists show that mechanisms improve during PDT treatment, but few studies have been able to study the effect of specific interventions on mechanisms during treatment. A notable exception is the study by Kivity et al. (2021) who studied how therapist “bids for RF” (interventions focusing on mental states) predicted better RF in borderline patients’ subsequent speech turns, and how this, in turn, predicted downregulation of patients’ arousal. At present, not all mechanisms and not all outcomes can be studied at this fine-grained level, but when possible, it is very persuasive.
Transference interpretation in patient subsamples
The findings from studies of transference interpretation are complex, with some studies showing negative effects for patients with low quality of internalized object relations (QOR) (Crits-Christoph et al., 2013). Still, the arguably methodologically strongest study to date (Hoglend et al., 2006) indicated the opposite, namely a more positive effect of transference interpretation on patients with low QOR. It is possible that the observational studies are influenced by reverse causation, that is, when therapy is not going well, therapists resort to transference interpretation as a means of resolving problems. There are similar findings for cognitive interventions in cognitive therapy (Castonguay et al., 1996). It is also possible that the finding is curvilinear, with (Hoglend et al., 2006) not including patients with the lowest levels of QOR in their study.
Differential mechanisms for various patient subgroups
It is likely that not all patients are affected equally by the same mechanisms of change. For instance, some PDT authors have argued that relationship factors are more important for more severely disturbed patients, while for more healthy patients, insight is the most important mechanism. We know of only two studies addressing such complexities. There is one small study (Town et al., 2022) showing different mediational pathways for more/less disturbed patients in Intensive Short-Term Dynamic Psychotherapy (ISTDP). This study showed that improved working alliance with the therapist was more important for more disturbed patients while insight was more important for more healthy patients. Another study by (Hoglend and Hagtvet, 2019) showed that the effect of transference interpretations on functioning for patients with low QOR was mediated by affect tolerance, which in turn predicted better insight.
References
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Crits-Christoph, P., Connolly Gibbons, M. B. & Mukherjee, D. (2013). Psychotherapy prcesss outcome research. In Bergin and Garfield´s handbook of psychotherapy and behavior change (ed. M. J. Lambert), pp. 298-340. Wiley: New York.
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