Intensive psychoanalytic therapy, the “talking cure” rooted in the ideas of Freud, has all but disappeared in the age of drug treatments and managed care.
In a review of 23 studies of such treatment involving 1,053 patients, the researchers concluded that the therapy, given as often as three times a week, in many cases for more than a year, relieved symptoms of those problems significantly more than did some shorter-term therapies.
The authors, writing in Wednesday’s issue of The Journal of the American Medical Association, strongly urged scientists to undertake more testing of psychodynamic therapy, as it is known, before it is lost altogether as a historical curiosity.
The review is the first such evaluation of psychoanalysis to appear in a major medical journal, and the studies on which the new paper was based are not widely known among doctors.
The field has resisted scientific scrutiny for years, arguing that the process of treatment is highly individualized and so does not easily lend itself to such study. It is based on Freud’s idea that symptoms are rooted in underlying, often longstanding psychological conflicts that can be discovered in part through close examination of the patient-therapist relationship.
Experts cautioned that the evidence cited in the new research was still too meager to claim clear superiority for psychoanalytic therapy over different treatments, like cognitive behavior therapy, a shorter-term approach. The studies that the authors reviewed are simply not strong enough, these experts said.
“But this review certainly does seem to contradict the notion that cognitive or other short-term therapies are better than any others,” said Bruce E. Wampold, chairman of the department of counseling psychology at the University of Wisconsin. “When it’s done well, psychodynamic therapy appears to be just as effective as any other for some patients, and this strikes me as a turning point” for such intensive therapy.
The researchers, Falk Leichsenring of the University of Giessen and Sven Rabung of the University Medical Center Hamburg-Eppendorf, both in Germany, reviewed only those studies in which the therapy had been frequent — more than once a week — and had lasted at least a year or, alternatively, had been 50 sessions long. Further, the studies had to have followed patients closely, using strict definitions of improvement.
The investigators examined studies that tracked patients with a variety of mental problems, among them severe depression, anorexia nervosa and borderline personality disorder, which is characterized by a fear of abandonment and dark squalls of despair and neediness.
Psychodynamic therapy, Dr. Leichsenring wrote in an e-mail message, “showed significant, large and stable treatment effects which even significantly increased between the end of treatment and follow-up assessment.”
The review found no correlation between patients’ improvement and the length of treatment. But improve they did, and psychiatrists said it was clear that patients with severe, chronic emotional problems benefited from the steady, frequent, close attention that psychoanalysts provide.
“If you define borderline personality broadly as an inability to regulate emotions, it characterizes a lot of people who show up in clinics, whether their given diagnosis is depression, pediatric bipolar or substance abuse,” said Dr. Andrew J. Gerber, a psychiatrist at Columbia. For some of those patients, Dr. Gerber said, “this paper suggests that you’ve got to get into longer-term therapy to make improvements last.”
Some psychoanalysts were more surprised by where the paper appeared than by its results: most review papers in major medical journals have hundreds of studies to draw on, or certainly far more than 23. The new review is encouraging, they said, but also a reminder of how much more study needs to be done.
Dr. Barbara L. Milrod, a professor of psychiatry at Weill Cornell Medical College, who like Dr. Gerber is a clinical practitioner of psychodynamic therapy, said further research was crucial as a matter of survival for a valuable treatment.
“Let’s be real,” Dr. Milrod said. “Major medical centers have been shutting down psychodynamic training programs because there isn’t an adequate evidence base.”