Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis

The Case for Duration

Leichsenring and Rabung’s 2008 meta-analysis, published in the Journal of the American Medical Association, addressed a question that the managed-care era had made taboo: does long-term psychodynamic psychotherapy work, and does it work better than shorter alternatives for the patients who need it most? The answer, drawn from 23 studies involving 1,053 patients, was unambiguous. For complex mental disorders — personality disorders, chronic depressive conditions, multiple comorbid diagnoses, and treatment-resistant anxiety — long-term psychodynamic psychotherapy (defined as treatment lasting at least one year or fifty sessions) produced large effect sizes that consistently exceeded those achieved by shorter-term treatments. The effect sizes were largest in precisely the domain that brief therapies most struggle to address: structural personality change.

Complexity Demands Depth

The paper’s significance lies in its implicit challenge to the one-size-fits-all model of psychotherapy delivery. The managed-care assumption — that twelve to sixteen sessions of manualized CBT represents the appropriate treatment for most psychological conditions — was never based on evidence that brief treatment works for complex patients. It was based on evidence that brief treatment works for carefully selected, relatively uncomplicated research participants. Leichsenring and Rabung demonstrate that the patients who present in actual clinical practice — with personality pathology, chronic depression, multiple diagnoses, and treatment histories marked by repeated failures — require something different: a sustained therapeutic relationship of sufficient duration to reach and reorganize the structural patterns that generate symptoms. This is what Jung called individuation and what contemporary psychodynamic theory calls structural change. It cannot happen in twelve sessions because the patterns that need to change were decades in the making and are woven into the patient’s character, relationships, and way of being in the world.

Personality Functioning as the Target

The meta-analysis reports its most striking findings in the domain of personality functioning — the patient’s characteristic patterns of relating, regulating affect, making meaning, and constructing identity. Long-term psychodynamic therapy produced effect sizes for personality change that dwarfed those achieved by shorter treatments. This finding is of particular significance for the Jungian tradition, which has always understood its therapeutic goal as transformation of the personality rather than amelioration of symptoms. Symptoms, in the depth view, are surface expressions of structural patterns in the psyche — complexes, archetypal defenses, unlived life — and addressing them without attending to their structural roots produces temporary relief followed by recurrence or symptom substitution. Leichsenring’s data confirm this clinical intuition: the treatments that produce the most durable changes in personality are the ones that take the time to reach the personality’s structural foundations.

The Institutional Context

That this paper appeared in JAMA — a journal whose readership consists overwhelmingly of physicians, not psychotherapists — was strategically significant. The marginalization of psychodynamic treatment in the twenty-first century has been driven less by evidence than by institutional economics: insurers prefer brief treatments, training programs prefer manualized protocols, and research funding agencies prefer randomizable interventions. Leichsenring and Rabung brought the countervailing evidence into the venue where it could not be ignored by the medical establishment. Whether that establishment has substantively responded is another question — but the evidence is now part of the permanent record.