Research on Internet-Based Psychodynamic Therapy

A quite recent innovation in the field of psychodynamic treatments is Internet-delivered psychodynamic therapy in the form of guided self-help. Importantly, this type of intervention is not about conducting psychodynamic or psychoanalytic psychotherapy via video conferencing methods, but rather it refers to structured, yet flexible, programs that patients can follow at their own pace online. One definition of such interventions is the following: “a therapy that is based on self-help books, guided by an identified therapist who gives feedback and answers to questions, with a scheduling that mirrors face to face treatment” (Andersson et al., 2008, p. 164)

These online interventions incorporate various psychodynamic principles, including the exploration of unconscious processes, identification of recurring patterns in relationships, and the unpacking of emotional experiences. A central feature of these programs is the facilitation of insight and self-reflection, enabling individuals to better understand their internal world and its manifestation in interpersonal dynamics.

The structured nature of Internet-delivered psychodynamic therapy often includes modules or chapters that the user works through sequentially. Each section typically builds upon the previous one, helping the individual to gradually develop a more cohesive understanding of their psychological make-up. Throughout the process, participants are encouraged to engage with reflective and experiential exercises, journaling prompts, and other interactive components designed to deepen their self-exploration.

A therapist, although not physically present, plays a crucial role in guiding the individual through the therapy. This is often achieved through regular asynchronous communication, such as email or messaging systems within the therapy platform. The therapist may provide personalized feedback on the exercises completed, answer questions that arise, and help the individual to make connections between the material in the program and their own life experiences. The aim is to maintain a level of therapeutic presence and support, akin to that provided in traditional face-to-face therapy. Details of how Internet-delivered psychodynamic therapy can be carried out can be found elsewhere (Johansson, Frederick, et al., 2013; Maroti et al., 2023).

The benefits of Internet-delivered psychodynamic therapy are numerous. For one, it offers greater accessibility, making it possible for those who may have barriers to traditional therapy, such as geographical limitations or mobility issues, to receive psychodynamic treatment. Moreover, the self-paced nature of the programs allows individuals to engage with the material at times that suit their schedules, potentially reducing the pressure and anxiety that can be associated with scheduled appointments.

Research into the efficacy of these online treatments has been promising, showing comparable results to traditional face-to-face psychodynamic therapy for a range of psychological issues (Johansson, 2019). However, it's important to note that Internet-delivered psychodynamic therapy may not be suitable for everyone. Individuals with severe mental health issues or those requiring more intensive support may benefit more from traditional therapeutic modalities.

In conclusion, Internet-delivered psychodynamic therapy represents a significant evolution in the realm of mental health treatment, offering a flexible and accessible approach for those seeking psychodynamic support. As technology advances and more research is conducted, it is likely that these programs will continue to be refined and their effectiveness further validated, making them a valuable addition to the therapeutic landscape.

Efficacy research

In total, 10 randomized controlled trials exist evaluating the effects of Internet-delivered psychodynamic therapy. Five RCTs exist regarding the treatment of adult depression and anxiety disorders (Andersson et al., 2012; Johansson, Björklund, et al., 2013; Johansson et al., 2012, 2017; Lemma & Fonagy, 2013). These studies typically show strong effects of Internet-based psychodynamic therapy when compared to control conditions, and several of these studies also report on increased effects from post-treatment to follow-up. Recently, two RCTs were published regarding adolescent depression (Lindqvist et al., 2020; Mechler et al., 2022). In one of these studies, Internet-based psychodynamic therapy was shown to be non-inferior to Internet-based cognitive behavior therapy. In addition to the studies already mentioned, there are two RCTs investigating the effects of online psychodynamic treatments supporting return to work, and as following in-patient psychotherapy (Zwerenz, Becker, Gerzymisch, et al., 2017; Zwerenz, Becker, Johansson, et al., 2017). Finally, one recent study investigated the effects of an Internet-delivered form of Emotional Awareness and Expression Therapy in the treatment of functional somatic disorders (Maroti et al., 2022). While Emotional Awareness and Expression Therapy draws from several psychological techniques or therapies, it has typically been included in summaries of short-term psychodynamic treatments (Abbass et al., 2020).

Process research

There is generally a lack of studies investigating processes of change in Internet-delivered psychodynamic therapy. One exception is the study on Internet-delivered Emotional Expression and Awareness Therapy in the treatment of functional somatic disorders (Maroti et al., 2022). In this study, the authors used the Emotional Processing Scale (Baker et al., 2010) to investigate mechanisms of change throughout therapy. In line with the authors’ predictions, one of the specific facets of emotional processing was related to positive outcome, even when controlling for other factors such as negative affect (Maroti et al., 2022).

Open research questions

- What are the effects of Internet-delivered psychodynamic therapy in the form of non-guided self help?

- Is Internet-delivered psychodynamic therapy non-inferior to face-to-face psychodynamic therapy, when compared head-to-head?

- Is Internet-delivered psychodynamic therapy as efficacious as other internet-delivered methods of psychotherapy?

- What are mechanisms of change in Internet-delivered psychodynamic therapy?

List of published RCTs:

1) Andersson, G., Paxling, B., Roch-Norlund, P., Östman, G., Norgren, A., Almlöv, J., Georén, L., Breitholtz, E., Dahlin, M., Cuijpers, P., Carlbring, P., & Silverberg, F. (2012). Internet-based psychodynamic versus cognitive behavioral guided self-help for generalized anxiety disorder: A randomized controlled trial. Psychotherapy and Psychosomatics, 81(6), 344–355. https://doi.org/10.1159/000339371

2) Johansson, R., Björklund, M., Hornborg, C., Karlsson, S., Hesser, H., Ljótsson, B., Rousseau, A., Frederick, R. J., & Andersson, G. (2013). Affect-focused psychodynamic psychotherapy for depression and anxiety through the Internet: A randomized controlled trial. PeerJ, 1, e102. https://doi.org/10.7717/peerj.102

3) Johansson, R., Ekbladh, S., Hebert, A., Lindström, M., Möller, S., Petitt, E., Poysti, S., Larsson, M. H., Rousseau, A., Carlbring, P., Cuijpers, P., & Andersson, G. (2012). Psychodynamic Guided Self-Help for Adult Depression through the Internet: A Randomised Controlled Trial. PLoS ONE, 7(5), e38021. https://doi.org/10.1371/journal.pone.0038021

4) Johansson, R., Hesslow, T., Ljótsson, B., Jansson, A., Jonsson, L., Färdig, S., Karlsson, J., Hesser, H., Frederick, R. J., Lilliengren, P., Carlbring, P., & Andersson, G. (2017). Internet-based affect-focused psychodynamic therapy for social anxiety disorder: A randomized controlled trial with 2-year follow-up. Psychotherapy, 54(4), 351–360. https://doi.org/10.1037/pst0000147

5) Lemma, A., & Fonagy, P. (2013). Feasibility study of a psychodynamic online group intervention for depression. Psychoanalytic Psychology, 30(3), 367–380. https://doi.org/10.1037/a0033239

6) Lindqvist, K., Mechler, J., Carlbring, P., Lilliengren, P., Falkenström, F., Andersson, G., Johansson, R., Edbrooke-Childs, J., Dahl, H.-S. J., Lindert Bergsten, K., Midgley, N., Sandell, R., Thorén, A., Topooco, N., Ulberg, R., & Philips, B. (2020). Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial. Journal of Medical Internet Research, 22(3), e18047. https://doi.org/10.2196/18047

7) Maroti, D., Lumley, M. A., Schubiner, H., Lilliengren, P., Bileviciute-Ljungar, I., Ljótsson, B., & Johansson, R. (2022). Internet-based emotional awareness and expression therapy for somatic symptom disorder: A randomized controlled trial. Journal of Psychosomatic Research, 163, 111068. https://doi.org/10.1016/j.jpsychores.2022.111068

8) Mechler, J., Lindqvist, K., Carlbring, P., Topooco, N., Falkenström, F., Lilliengren, P., Andersson, G., Johansson, R., Midgley, N., Edbrooke-Childs, J., Dahl, H.-S. J., Sandell, R., Thorén, A., Ulberg, R., Bergsten, K. L., & Philips, B. (2022). Therapist-guided internet-based psychodynamic therapy versus cognitive behavioural therapy for adolescent depression in Sweden: A randomised, clinical, non-inferiority trial. The Lancet Digital Health, 4(8), e594–e603. https://doi.org/10.1016/S2589-7500(22)00095-4

9) Zwerenz, R., Becker, J., Gerzymisch, K., Siepmann, M., Holme, M., Kiwus, U., Spörl-Dönch, S., & Beutel, M. E. (2017). Evaluation of a transdiagnostic psychodynamic online intervention to support return to work: A randomized controlled trial. PloS One, 12(5), e0176513. https://doi.org/10.1371/journal.pone.0176513

10) Zwerenz, R., Becker, J., Johansson, R., Frederick, R. J., Andersson, G., & Beutel, M. E. (2017). Transdiagnostic, Psychodynamic Web-Based Self-Help Intervention Following Inpatient Psychotherapy: Results of a Feasibility Study and Randomized Controlled Trial. JMIR Mental Health, 4(4), e41. https://doi.org/10.2196/mental.7889