Long Term Psychodynamic Psychotherapy

psychodynamic treatment

Long-term psychodynamic psychotherapy (LTPP) occupies a contested and increasingly evidence-fortified position within the depth-psychology corpus. The central scholarly tension runs between the persistent institutional skepticism toward psychoanalytically derived treatments and the mounting empirical record demonstrating their efficacy, particularly for complex, chronic, and personality-disordered populations for whom briefer interventions prove insufficient. Leichsenring and Rabung’s landmark 2008 meta-analysis in JAMA stands as the field’s definitive quantitative statement, reporting large between-group effect sizes for overall outcome, target problems, and personality functioning that dwarf those achieved by comparison treatments. De Maat and colleagues’ 2009 systematic review extends this lineage while foregrounding methodological debates over study design, pooling strategies, and the heterogeneity of patient populations. Shedler’s 2010 synthesis adds the provocative argument that therapeutic gains from psychodynamic treatment not only endure but continue to grow post-termination — a ‘sleeper effect’ absent from most competing modalities. The corpus also registers the complexity of evidence standards in psychotherapy research: the impossibility of double-blinding, the tension between internal and external validity, and the question of what constitutes an adequate comparison condition. Across these works, the treatment of complex mental disorders — personality pathology, chronic depression, comorbid presentations — emerges as LTPP’s primary domain of demonstrated advantage.

In the library 20 passages

convincing research on the outcome of long-term psychodynamic psychotherapy (LTPP) has been lacking… Evidence… indicates that short-term treatments are insufficient for a considerable proportion of patients with complex mental disorders

Leichsenring establishes the foundational rationale for LTPP research by identifying the gap between the insufficiency of short-term treatments for complex presentations and the absence of meta-analytic evidence for LTPP.

Leichsenring, Falk, Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, 2008thesis

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after treatment with LTPP patients on average were better off than 96% of the patients in the comparison groups

This passage reports the meta-analysis’s most striking quantitative finding: that LTPP produces between-group effect sizes for overall outcome, target problems, and personality functioning so large that the average LTPP patient outperforms nearly all comparison-group patients.

Leichsenring, Falk, Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, 2008thesis

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patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends

Shedler argues that psychodynamic therapy’s empirical standing is systematically underappreciated, and that its distinctive feature — ongoing improvement after termination — distinguishes it from competing evidence-based treatments.

Shedler, Jonathan, The Efficacy of Psychodynamic Psychotherapy, 2010thesis

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benefits of psychodynamic therapy endure but increase with time, a finding that has now emerged from at least five independent meta-analyses

Shedler synthesizes convergent evidence across five independent meta-analyses to establish that psychodynamic therapy sets in motion continuing psychological change, a finding that contrasts with the decay of benefits observed in other empirically supported treatments.

Shedler, Jonathan, The Efficacy of Psychodynamic Psychotherapy, 2010thesis

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enduring benefits of psychodynamic therapy five years after treatment completion… 87% of patients who received ‘treatment as usual’ continued to meet diagnostic criteria for borderline personality disorder, compared with 13% of patients who received psychodynamic therapy

Drawing on Bateman and Fonagy’s long-term follow-up data, Shedler demonstrates that psychodynamic therapy produces uniquely durable remission in borderline personality disorder, with no other treatment for personality pathology showing comparable sustained effects.

Shedler, Jonathan, The Efficacy of Psychodynamic Psychotherapy, 2010thesis

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LTPP alone yielded significant effect sizes for overall outcome, target problems, general psychiatric symptoms, and social functioning at post-test time points… All these effect sizes were more than 0.80 indicating large effects

Leichsenring’s sub-analysis of personality disorder studies demonstrates that LTPP alone — without combined psychotropic medication — produces uniformly large effects across all outcome domains.

Leichsenring, Falk, Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, 2008supporting

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LTPP yielded significant before-after effect sizes for all outcome domains with the exception of personality functioning. All effect sizes including those at follow-up were more than 0.80

Reporting results for chronic mental disorder subgroups, Leichsenring documents consistently large pre-post effect sizes for LTPP across clinical outcome domains, with effects maintained at follow-up.

Leichsenring, Falk, Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, 2008supporting

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strong evidence-based support for LTPP has been lacking. No meta-analysis addressing the outcome of LTPP has yet been published… This article reports the first meta-analysis to our knowledge on the outcome of LTPP

Leichsenring situates his 2008 meta-analysis as the inaugural systematic quantitative synthesis of LTPP outcome evidence, filling a recognized gap in the evidence-based psychotherapy literature.

Leichsenring, Falk, Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, 2008supporting

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Doidge evaluated nine quantitative studies of psychoanalysis and concluded that ‘for the properly chosen patient, psychoanalysis is effective in terms of symptom relief, character changes, and conflict resolution’

De Maat surveys the pre-meta-analytic review literature, tracing how earlier systematic appraisals — particularly Fonagy’s Open Door Review and Doidge’s evaluation — laid the evidential groundwork for LTPP’s empirical case while noting their methodological limitations.

de Maat, Saskia, The Effectiveness of Long-Term Psychoanalytic Therapy: A Systematic Review of Empirical Studies, 2009supporting

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in psychotherapy research… double-blind studies cannot be realized because the patients know or can easily find out which treatment they receive

Leichsenring addresses a fundamental methodological constraint on psychotherapy outcome research, arguing that the standard double-blind criterion cannot be mechanically applied to LTPP studies and that the Jadad quality scale must be adapted accordingly.

Leichsenring, Falk, Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, 2008supporting

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The effect size increased to 1.51 when the patients were assessed at long-term follow-up… The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic therapy sets in motion psychological processes that lead to ongoing change

Shedler documents the post-treatment growth of psychodynamic therapy effects across multiple symptom domains, interpreting the escalating effect sizes at follow-up as evidence of a distinctive mechanism of continuing intrapsychic change.

Shedler, Jonathan, The Efficacy of Psychodynamic Psychotherapy, 2010supporting

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The mean (SD) number of sessions carried out in the 23 studies of LTPP was 151.38 (154.98) and a median of 73.50. The duration of therapy was 94.81 (58.79) weeks

Leichsenring provides descriptive parameters for the LTPP treatment conditions included in his meta-analysis, establishing the empirical referent for what ‘long-term’ signifies in this literature in terms of session count and treatment duration.

Leichsenring, Falk, Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, 2008supporting

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See F. Leischenring and S. Rabung, ‘Effectiveness of Long-Term Psychodynamic Psychotherapy: A Meta-Analysis,’ JAMA… Bateman and P. Fonagy, ‘Eight-Year Follow-Up of Patients Treated for Borderline Personality Disorder’

Herman’s reference apparatus in the revised edition of Trauma and Recovery explicitly cites both Leichsenring’s LTPP meta-analysis and Bateman and Fonagy’s eight-year follow-up, situating LTPP evidence within the trauma treatment literature.

Herman, Judith Lewis, Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror, 1992supporting

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Focus on affect and expression of emotion. Psychodynamic therapy encourages exploration and discussion of the full range of a patient’s emotions… intellectual insight is not the same as emotional insight, which resonates at a deep level and leads to change

Shedler articulates the distinctive process features of psychodynamic therapy — emphasis on affect, avoidance exploration, and emotional rather than intellectual insight — that constitute its active therapeutic mechanisms and distinguish it from cognitive-behavioral approaches.

Shedler, Jonathan, The Efficacy of Psychodynamic Psychotherapy, 2010supporting

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effect sizes were independently assessed by the 2 raters. Interrater reliability was assessed for the outcome domains in question… For all areas, interrater reliability was satisfactory (r ≥ 0.80)

Leichsenring documents the methodological rigor of his meta-analytic coding procedure, reporting strong interrater reliability across the five outcome domains used to evaluate LTPP studies.

Leichsenring, Falk, Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, 2008supporting

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Psychotherapies have established effectiveness in some of these conditions… Common treatment options in these settings include psychotherapy (e.g. psychodynamic psychotherapy, cognitive behavioural therapies), medications

Abbass positions psychodynamic psychotherapy within the broader landscape of evidence-based treatments for common mental disorders, providing context for understanding LTPP’s place relative to short-term and non-psychodynamic alternatives.

Abbass, Allan A, Short-term psychodynamic psychotherapies for common mental disorders, 2014aside

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It is difficult to do research on therapy that is not contained in a manual, relies on a long apprenticeship and is better described as an art or craft than a science, but it is nevertheless necessary

A contributor to Lanius’s trauma volume articulates the fundamental methodological challenge confronting long-term psychodynamic approaches: their resistance to manualization and their craft-based transmission make outcome research structurally difficult yet indispensable.

Lanius, edited by Ruth A, The impact of early life trauma on health and disease the, 2010aside

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relatively few clinical practitioners, including psychodynamic practitioners, are familiar with the research reviewed in this article… distrust of academic research methods may have impeded dissemination in psychoanalytic circles

Shedler identifies a paradox in which the empirical evidence base for psychodynamic therapy remains poorly disseminated within psychoanalytic communities themselves, attributing this to mutual suspicion between practitioners and researchers.

Shedler, Jonathan, The Efficacy of Psychodynamic Psychotherapy, 2010aside

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Sensorimotor psychotherapy builds on traditional psychotherapeutic understanding but approaches the body as central… incorporates theory and technique from psychodynamic psychotherapy, cognitive–behavioral therapy, neuroscience, and theories of attachment and dissociation

Ogden positions sensorimotor psychotherapy as an integrative modality that draws selectively on psychodynamic theory and technique while adding somatic interventions not traditionally practiced within depth-psychological frameworks.

Ogden, Pat, Trauma and the Body: A Sensorimotor Approach to Psychotherapy, 2006aside

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