Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054

Psychodynamic psychotherapy: article developing the evidence base Jessica Yakeley

In this article I will outline recent develop­ments Jessica Yakeley is a consultant SUMMARY in the field of psychodynamic psychotherapy psychiatrist in forensic psycho­ therapy at the Portman Clinic, and Psychodynamic psychotherapy has been research that go some way in refuting these criticised as being based on outdated principles of Director of Medical Education criticisms. Contrary to the beliefs of some and Associate Medical Director psychoanalysis and lacking an adequate evidence detractors of psychodynamic psychotherapy, there at the Tavistock and Portman NHS base to convincingly demonstrate its efficacy. is now a convincing body of empirical evidence Foundation Trust. She is currently This article summarises the recent evidence the Lead on Meaningful Evaluation from high-quality outcome studies to show that from well-designed outcome studies to support of Psychotherapy Services for the psychodynamic psychotherapy is as effective in its efficacy. Moreover, process–outcome research Medical Psychotherapy Faculty of the treatment of a range of mental disorders as linking specific psychodynamic interventions the Royal College of Psychiatrists other psychological treatment modalities such to therapeutic outcomes within a theoretical and Chair of the Research and Evidence Task Group of the British as cognitive–behavioural therapy, as well as framework based on attachment has facilitated Psychoanalytic Council. reviewing process–outcome research aiming better understanding of the processes of change Correspondence Dr Jessica to elucidate mechanisms of therapeutic change. and enabled therapeutic technique to be adapted Yakeley, Portman Clinic, 8 Fitzjohns Avenue, London NW3 5NA, UK. A paradigm for psychodynamic psychotherapy and refined, with the development of tailored research based on attachment theory is Email: [email protected] psycho­dynamic psychotherapies for specific introduced, which may inform the development of conditions. psychodynamic therapeutic modalities tailored for specific conditions. What is psychodynamic psychotherapy? LEARNING OBJECTIVES Psychodynamic psychotherapy has its historical • Understand the basic principles and techniques origins in Freud’s work and is based on the of psychodynamic psychotherapy. fundamental principles of psychoanalysis. These • Be able to summarise the recent evidence base include the dynamic unconscious, transference, for the efficacy of psychodynamic psychotherapy. countertransference, resistance, defence, psychic • Appreciate process–outcome research that determinism (the notion that our thoughts and elucidates therapeutic mechanisms underpinning actions are determined by unconscious forces and psychodynamic psychotherapy. have symbolic meaning), and a developmental DECLARATION OF INTEREST perspective, in which childhood experiences are None. seen as critical in shaping the adult personality. Although the terms ‘psychoanalytic psychotherapy’ and ‘psychodynamic psychotherapy’ are often used Psychodynamic psychotherapy has been belea­ interchangeably, psychodynamic psychotherapy guered in recent times. Accusations that it is may be viewed as encompassing a broader based on outdated principles of psychoanalysis, perspective which includes the ‘relational’, i.e. that it lacks an empirical research base and the interpersonal, intersubjective and embodied that its emphasis on longer-term treatments by experience of both the social world and the highly trained pro­fessionals makes it less cost- internal world, in which representations are built effective than other psychological treatments have up over time and reflect dispositions that arise contributed to the dismantling of psychodynamic from innate vulnerability and early childhood psychotherapy services within the National Health experience. It also refers to the dynamic nature Service (NHS) in favour of more ‘evidence-based’ of both the internal and external worlds in that interventions. Although the economic recession has they shift and change in the context of social been a challenge to all mental health services forced relationships and group settings experienced over to make financial savings, reports suggest that a lifetime (Yakeley 2013). psycho­dynamic psycho­therapy provision within the public health sector has been disproportionately Free association reduced compared with other treatment modalities Traditional psychodynamic psychotherapy (British Psychoanalytic Council 2013). utilises techniques derived from psychoanalysis,

269 Yakeley

but sessions are less frequent, provided once Box 1 Seven features that distinguish or twice a week over a shorter time span, and psycho­dynamic psychotherapy from ‘face to face’, with the patient sitting up rather other therapies than lying on the couch as in psychoanalysis.

In contrast to therapies where the therapist sets • Focus on affect and expression of emotion

an agenda or actively structures the session, the • Exploring attempts to avoid distressing thoughts and patient is encouraged to say whatever is in their feelings (defence and resistance) mind, following the psychoanalytic technique of • Identifying recurring themes and patterns ‘free association’. The psychotherapist’s task is • Discussion of past experience (developmental process) to discover the unconscious themes that underlie the patient’s discourse via the patient’s slips of • Focus on interpersonal relations the tongue, associative links and resistances to • Focus on the therapy relationship (including speaking about certain topics that the patient is transference) unaware of. The psychotherapist intervenes in • Exploration of wishes and fantasies the form of verbal communications, which can (Blagys 2000) be categorised along a spectrum from the more supportive or empathic, to more challenging and interpretative as the therapy progresses. identify empirical studies comparing manualised psychotherapy technique with that of manualised Interpretative and supportive interventions CBT. From empirical examination of recordings Interpretative interventions enhance the patient’s and transcripts of actual sessions they identified insight about repetitive conflicts sustaining their seven distinctive features concerning process and problems (Gabbard 2004), and offer a new formu­ technique that reliably distinguished psycho­ lation of unconscious meaning and motivation for dynamic psychotherapy from other therapies the patient. ‘Transference interpretations’, focusing determined (Box 1). on the relationship between therapist and patient in the ‘here and now’ or affective interchange of Specific psychodynamic therapeutic the session, are often viewed by contemporary modalities therapists as the most mutative interventions. In A number of distinct psychodynamic psycho­ practice, the therapist adopts a flexible approach therapies or modalities have evolved which so that any session may include a combination combine elements from other approaches, including of supportive and interpretative interventions the interpersonal, humanistic and cognitive according to the patient’s need and mental state traditions. These therapies have usually been at the time. developed and tailored for a specific disorder, such as depression or borderline personality disorder, The countertransference but subsequently generalised to treat a wider range Psychodynamic psychotherapists also pay special of conditions. They tend to be time-limited, have a attention to the therapist’s countertransference, clear theoretical basis and promote modifications that is, the feelings and emotional reactions that of specific techniques, which are defined and the therapist has towards the patient. These illustrated in manuals. Such manualisation is can be a source of useful information about the helpful in communicating and disseminating what patient and their internal object relations, which exactly occurs in the therapy under question, but determine their pattern of relating to others. is also necessary to ensure consistent training, interrater reliability and adherence to the model in Core features of contemporary psychodynamic outcome studies of treatment efficacy. Such studies psychotherapy have significantly contributed to the evidence base Although the concepts and techniques of psycho­ for psychodynamic psychotherapy in general (see dynamic psychotherapy have evolved considerably below). since Freud and have led to the development of Table 1 lists the main modalities of modified a range of specific psychodynamic therapeutic psychodynamic therapies that have been developed modalities for different conditions, core features and are available to at least some extent within the of contemporary psychodynamic psychotherapy NHS and public health sector in the UK. Most of may be distinguished that differentiate it from these therapies are only available in specialised other therapies such as cognitive–behavioural mental health or psychological services, but therapy (CBT). Blagys & Hilsenroth (2000) dynamic interpersonal therapy is available as one conducted a comprehensive literature search to of the brief psychotherapies provided nationally

270 Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 Psychodynamic psychotherapy: developing the evidence base

as part of the Increasing Access to Psychological table 1 Main psychodynamic therapies available in the UK’s National Health Service Therapies (IAPT) programme introduced by the Department of Health in 2007 (Department of Therapy & Clinical Health 2007). studies Core features indications Interpersonal Brief, focused, structured therapy emphasising current Depression The research challenges for therapy (IPT) interpersonal relations. Four focuses: grief, disputes, (Klerman 1996) deficits and role transition psychodynamic psychotherapy Psychodynamic Psychodynamic therapy with humanistic and Depression, The limitations of the empirical base for psycho­ interpersonal interpersonal elements, consisting of seven somatisation dynamic psychotherapy have been well rehearsed. therapy (PIT) integrated components: explanatory rationale, shared (Hobson 1985; understanding, staying with feelings, focus on difficult First, the psychoanalytic community as a whole Guthrie 1991, feelings, gaining insight, sequencing interventions and has been historically disinterested or resistant to 1999) making changes the value of research, which has resulted in the Dynamic Brief focused therapy based on distillation of evidence- Depression, critical scientific evaluation of psychodynamic interpersonal based manualised psychodynamic approaches, anxiety disorders therapy (DIT) incorporating object relations, attachment and treatments lagging behind the evaluation of other (Lemma 2010) mentalisation theory. Focuses on patient’s interpersonal forms of psychiatric and psychological interven­ and affective functioning in ‘here and now’ of session tions (Gerber 2010). This resistance may be Cognitive Brief therapy integrating psychoanalytic and cognitive Neurotic due to a variety of reasons, including suspicion analytic therapy techniques, emphasising patient’s relationships. disorders, of research methods such as manualisation of (CAT) Constructs reformulation of difficulties with patient borderline (Ryle 1982, defining ‘reciprocal role procedures’ based on early personality treatments, randomisation of patients or recording 1990) relationships, and defensive mechanisms maintaining disorder of sessions; viewing narrowly defined trial criteria them (‘traps’, ‘dilemmas’ and ‘snags’) and research conditions as non-representative Mentalisation- Group and individual therapy based on attachment Borderline of clinical practice (i.e. the gap between clinical based therapy theory integrating psychodynamic, cognitive and personality efficacy and effectiveness); and a reluctance (MBT) relational components. Focuses on enhancing disorder, eating (Bateman 2004, mentalisation (the ability to reflect on one’s own and disorders, to give up cherished beliefs about theory and 2006) others’ states of mind and link these to actions and depression, technique based on individual experience and behaviours) substance clinical lore rather than a willingness to take on misuse, parenting difficulties board empirical findings which may challenge Transference- Individual therapy two or three times a week, based on Borderline and established practice. focused psycho­ psychoanalytic object relations theory using modified other severe Second, many of the trials of psychodynamic therapy (TFT) psychoanalytic techniques. Focuses on the reactivation personality psychotherapy that have been conducted have (Clarkin 2006; and interpretation of the patient’s split-off internalised disorders Kernberg 2008) object relations in the transference lacked sufficient methodological rigour, for exam­ ple, in unclear definitions of patient characteristics or treatment methods, inadequate sample sizes, past two decades there has been an increasing poor monitoring of adherence to the treatment number of high-quality RCTs in psychodynamic model and interrater reliability, and less than opti­ psychotherapy. Shedler (2010) has highlighted the mal control conditions in which treatment as usual importance of several key meta-analyses published is used instead of an alternative potential active in high-impact journals, which pool the results of treatment. The number of randomised controlled these studies and demonstrate that effect sizes trials (RCTs) of psychodynamic psychotherapy is (Box 2) for psychodynamic psychotherapies are as small compared with those that have been carried large as those reported for other treatments that out in the evaluation of other forms of psycho­ have been actively promoted as ‘evidence-based’, therapy, particularly CBT. such as CBT. Third, many of these studies have focused on For example, a meta-analysis published by the brief psychodynamic treatments, whereas many Cochrane Library (Abbass 2006) reviewed 23 RCTs psychodynamic clinicians are interested in comparing short-term psycho­dynamic psycho­ elucidating the mechanisms of change of longer- therapy for common mental disorders­ against term treatments which aim at deeper structural minimal treatment and non-treatment control changes in the patient’s personality organisation interventions, yielding an overall effect size of 0.97 rather than solely symptom improvement. for general symptom improvement, which increased to 1.51 when the patients were assessed at 9-month Outcome studies of psychodynamic follow-up. Another meta-analysis, reported in psychotherapy Archives of General Psychiatry, of 17 high-quality RCTs reported an effect size of 1.17 for short-term Meta-analyses and effect sizes psychodynamic psychotherapy compared with Despite these challenges in conducting methodo­ control interventions (Leichsenring 2004). Two logically robust research in the field, in the more recent meta-analyses, published in the JAMA

Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 271 Yakeley

well as manual searches of articles and textbooks, Box 2 Research terminology and communication with authors and experts in Efficacy measures how well an intervention summarising and integrating the findings of the field. The search criteria identified all RCTs or treatment works in clinical trials designed independent studies of a specific treatment, published between January 1970 and September to show internal validity so that causal that in themselves are too small or limited 2013 that examined the efficacy of psychodynamic inferences may be made. in scope, to come to a conclusion about psychotherapy for specific mental disorders using treatment efficacy. treatment manuals and reliable and valid measures Clinical effectiveness is the extent to for diagnosis and outcome. Meta-analysis of the 47 which an intervention or treatment improves Effect size refers to the difference between the outcome for patients in everyday clinical treatment and control groups, expressed RCTs that met these rigorous criteria showed that practice. There is often a gap between in standard deviation units. An effect size psychodynamic therapy is efficacious for a range efficacy and effectiveness. of 1.0 indicates that the average patient of common mental disorders, including depressive receiving the treatment under consideration disorders, anxiety disorders,­ somatoform disorders, Meta-analysis is a widely accepted is one standard deviation healthier on the personality disorders, eating disorders, complicated method used in medicine and psychology normal distribution than the average patient grief, post-traumatic stress disorder and substance- to strengthen the evidence about treatment receiving no treatment. An effect size related disorders. efficacy. It refers to the statistical analysis of 0.8 is considered a large effect, 0.5 is of a collection of results for the purpose of considered moderate, 0.2 is small. The Dodo verdict This accumulation of empirical evidence convincingly demonstrates that psychodynamic (Leichsenring 2008, 2009) and the Harvard Review psychotherapy is not inferior in efficacy to other of Psychiatry (de Maat 2009), have examined the psychological treatments. Moreover, it shows that efficacy of long-term psychodynamic psychotherapy the benefits of psychodynamic psychotherapy (1 year or more) for a range of DSM diagnoses may be long lasting and extend beyond symptom and complex mental disorders. These found that remission. However, perhaps para­doxically, the the effect sizes for longer-term psychodynamic methodological superiority of more recent trials, psychotherapy were not only significantly higher which have included active treatments as controls, than those for the shorter-term therapies, but that has highlighted the well-known ‘Dodo verdict’ they continued to increase from termination of (Rosenzweig 1936; Luborsky 1975), based on the treatment to long-term follow-up, especially for conclusion of the dodo in Alice in Wonderland that patients with severe personality pathology. ‘Everybody has won and all must have prizes’. This refers to the consistent finding in psychotherapy Outcomes for specific disorders research of the outcome equivalence of different Many of the studies in these meta-analyses, therapies, in that no specific therapy is shown to however, included patients with a range of symp­ have greater efficacy than any other. toms and conditions, rather than focusing on This finding is usually interpreted as being specific diagnostic categories. Other recent due to ‘common factors’, i.e. techniques and meta-analyses have focused on the evidence mechanisms common to different therapies which base for psychodynamic psychotherapy for constitute the agents of change and are frequently specific disorders. subsumed under the umbrella of the ‘therapeutic Thus, Abbass et al (2009), in a meta-analysis alliance’. How­ever, the dodo verdict here might of 23 studies examining the efficacy of short- also be due to a failure to measure real differences term psychodynamic psychotherapy for somatic that exist between different therapies but have disorders, reported an effect size of 0.69 for eluded detection because our measures are improvement in general psychiatric symptoms and inadequate. In the case of psychodynamic psycho­ 0.59 for improvement in somatic symptoms. therapy, there may be a fun­damental mismatch A meta-analysis looking at the efficacy of both between what outcome studies tend to measure in psycho­dynamic psychotherapy and CBT for improvement or alleviation of symptoms and what personality disorder published in the American psychodynamic psychotherapy aims to achieve in Journal of Psychiatry (Leichsenring 2003) showed going beyond symptom remission to change deeper pre- to post-treatment effect sizes of 1.46 for personality structures and capacities, enabling the psycho­dynamic psychotherapy and 1.0 for CBT. patient to live with greater freedom and possibility In a very recent publication, Leichsenring & (Shedler 2010). Klein (2014) review the empirical evidence for psychodynamic therapy for specific mental disorders What works and how? in adults. They conducted a computerised search Such questions have prompted a shift in of MEDLINE, PsycINFO and Current Contents, as psycho­therapy research from outcome to

272 Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 Psychodynamic psychotherapy: developing the evidence base

‘process–outcome’ research, in which the focus is table 2 Summary of techniques and attributes that contribute positively to the on elucidating specific processes and mechanisms therapeutic relationship of therapeutic change, what works for whom and under what conditions. These research efforts Techniques positively related to alliance Attributes positively related to alliance aim to more clearly link theories of personality Supportive Helpful, affirming, understanding, accepting, development and the aetiology of specific disorders (e.g. affirm patient’s experience, note past collaborative, enthusiastic to the processes of change, and to explicate the therapy success, convey sense of connection) corresponding therapeutic techniques necessary Exploratory Open, empathic, warm, friendly, egalitarian (e.g. open-ended questions, clarify areas to achieve them. of distress, foster depth, non-hostile confrontation, accurate interpretation) Therapeutic alliance Experiential and affect focused Honest, trustworthy, respectful An extensive body of research studies have (e.g. attend to and reflect patient’s experience, facilitate expression of affect, consistently shown that there is a significant explore different emotional states) relationship between the therapeutic alliance and Engaged and active relationship Interested, alert, flexible, confident, the process of therapy, and that the therapeutic (e.g. active involvement, focus on ‘here and experienced, competent relationship is one of the most robust predictors of now’, ongoing feedback) positive outcome across all modalities, regardless After Hilsenroth et al (2012). of whether this is measured by the therapist, the patient or an independent observer. In an extensive attitude in giving support, affirmation and noting review of studies of therapeutic alliance research, encouraging changes as treatment progresses may which included insight-oriented, experiential, be viewed by some therapists as interfering with humanistic, cognitive–behavioural, interpersonal the emergence and detection of more negative and relational models of psychotherapy, Hilsenroth transference reactions which they believe need et al (2012) identified four categories of therapist to be brought into the open and interpreted to techniques that are found to contribute positively facilitate therapeutic progress. Similarly, more to the alliance and predict better therapeutic traditional psychoanalytic therapists may fear that outcomes: supportive, exploratory, ‘experiential- a more active stance on the part of the therapist affect focused’ and ‘engaged-active relationship’ may hinder the process of free association and (Table 2). Box 3 lists the therapist techniques that spontaneous emergence of unconscious material have been shown to detract from the therapeutic in the patient’s discourse. However, the empirical alliance and hinder the therapeutic process. findings on the role of transference interpretations One of the key findings in research on the perhaps pose the greatest challenge to therapeutic alliance is that disruptions or ruptures contemporary psychoanalytic technique in which in the alliance are generated from patients’ negative the roles of transference and countertransference reactions to the therapist and/or treatment process, are deemed central. and that addressing these within the therapeutic frame is critical to the repair and maintenance Defence, resistance and transference of a positive therapeutic alliance with better Process research attempts to examine some of therapeutic outcome. Careful awareness of the the fundamental principles and techniques of therapeutic relationship is recommended from the psychoanalytic psychotherapy and their effects by start, so that a positive therapeutic relationship can develop as soon as possible. Box 3 Techniques that contribute negatively Do empirical findings support traditional teaching and to the therapeutic relationship practice? • Managing the treatment in an inflexible manner It is worth considering the extent to which these empirical findings on aspects of the therapeutic • Failure to structure the therapy alliance associated with better outcome match the • Over-structuring the therapy established teaching and practice of psychodynamic • Inappropriate self-disclosure psychotherapy. A focus on the patient’s affect and • Inappropriate use of silence subjective experience within the sessions and in- • Unyielding transference interpretations depth exploration of their problems conveyed by • Belittling or hostile communications accurate high-quality interpretations would be accepted by most psychoanalytically oriented • Superficial interventions clinicians as recommended therapeutic technique. (Hilsenroth 2012) However, techniques that openly convey a positive

Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 273 Yakeley

focusing on the microprocesses occurring within Rosser et al (1983), in a study of 32 patients with the ongoing communications between therapist respiratory disease randomised to eight sessions and patient during the therapy. of psycho­analytic psychotherapy in which the analyst was instructed either to make free use of Defence and resistance transference interpretations or to withhold such One of the fundamental techniques of psycho­ inter­pretations, found that change in psychiatric analytic psychotherapy is the elucidation and symp­toms was significantly greater in the latter interpretation of the patient’s unconscious defences group. Other studies have shown that higher ‘doses’ and their resistances to therapeutic change. of transference interpretations (frequency per Defences are automatic mechanisms occurring session) were associated with poorer therapeutic out of conscious awareness that deal with internal alliance, increased levels of defensiveness in the and external anxieties, stresses and conflicts – the patients and poorer outcomes (Piper 1991; Høglend unconscious equivalent of ‘coping mechanisms’. We 1993; Connolly 1999; Ogrodniczuk 1999). all use an array of defence mechanisms that have These findings have been criticised on the basis evolved from childhood, ranging from the more that most of these studies involved very brief primitive to the more mature and appropriately psychotherapy, were based on naturalistic studies, adaptive, many of which have become enduring and showed wide variability in the number personality traits. However, individuals with of transference interpretations per session, personality difficulties or disorders tend to utilise ranging from 5 to over 50% of all interpretative less mature or more primitive defence mechanisms interventions by the therapist (Høglend 2012; such as projection, splitting or denial, with an Luyten 2012). adverse impact on their psychological functioning In a sophisticated RCT looking at both process and interpersonal relationships. and outcome of 100 patients with mixed anxiety Process research into defence interpretation and depressive disorders, Høglend and colleagues can assess such defences on a moment-to- (2008) looked at the longer-term effects of moment basis, comparing a patient’s defences trans­ference interpretations. The patients were before and after an intervention. Outcome randomised to psychodynamic psychotherapy of 1 studies have shown that defences and defensive year’s duration with transference interpretations functioning become more flexible and improve or to therapy without such interpretations, with with treatment, so that the person’s responses to follow-up at 1 and 3 years. The authors found no conflict and adversity in relation to themselves difference in efficacy between the two treatments and others are more appropriate. Such research either at termination or at long-term follow-up, has also demonstrated the role of defences in except in patients who had low levels of personality mediating treatment by improving symptoms and organisation or object relating as measured on the how therapeutic interventions lead to changes in Quality of Object Relations scale. These patients defensive functioning within and across sessions with more severe personality pathology responded (Perry 2012). better to treatment containing low levels of trans­ ference interpretations (0–3 per session) compared Transference with treatment without such interpretations. Another hallmark of psychoanalytic psychotherapy Increased insight in these patients mediated the is interpretation of the transference, which, as men­ relationship between transference interpretations tioned earlier, many believe is the most mutative and improvements in relational functioning. intervention in fostering insight. However, the few studies that have attempted to investigate the Interpreting the findings relationship between transference interpretations Caution must be exerted in interpreting these and outcome have produced equivocal results. In findings. In clinical practice there is a wide an early study reviewing therapist notes recalled by variation in content, depth, quality and timing of the therapist after sessions, Malan (1976) reported transference interpretations and in whether care a positive correlation between interpretations that or hostility is communicated, all of which will vary linked the patient’s relationship to the therapist according to the countertransference experiences to that of the patient’s parents (‘transference- and subjectivity of the therapist. Moreover, there parent linking interpretations’) and positive out­ is a significant difference between a more classic come, a finding replicated by Marziali (1984) in understanding of transference, in which the a study of audiotaped sessions. However, Piper focus is on linking the patient’s relationship to et al (1986) found that transference interpretations the therapist to past significant others, and the were uncorrelated with outcome. Furthermore, more contemporary relational perspective, in

274 Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 Psychodynamic psychotherapy: developing the evidence base

which the patient’s ‘here and now’ experiences of The therapist as a secure base and temporary the therapist are explored with no explicit link attachment figure to the past. Nevertheless, although the research Attachment theory has thus provided empirical indicates that a moderate level of transference evidence for certain fundamental psychoanalytic interpretations may mediate increase in insight, principles, particularly the notion that childhood leading to better outcomes in longer-term therapy, experiences are critical in shaping the adult a high frequency of transference interpretations character, mental health and pathology, as well may be counterproductive, particularly in more as validating key psychoanalytic concepts such ‘difficult’ patients, as it serves to increase their as transference and countertransference. The hostility and resistance by fortifying their defences developmental perspective of attachment theory to ward off perceived attacks. provides a framework for psychotherapy in which the therapist is experienced as a secure base and Attachment theory temporary attachment figure for the patient. Attachment theory is perhaps the most convincing This enables the patient to explore past and theoretical framework guiding psychodynamic present relationships, external to and within the treatment and research today, providing a therapy, with the opportunity to revise internal coherent model in which the findings on the working models, leading to better adaptation influence of the therapeutic alliance and the and interpersonal relating. Transference and effects of other psychotherapeutic techniques countertransference may be used to examine and may be conceptualised, integrated and further address the multiple and contradictory internal empirically tested. However, although Bowlby working models that emerge within the therapeutic was a psychoanalyst, for many years his ideas and relationship and help the patient develop new ways empirical findings regarding child development of feeling and behaving based on current rather were rejected by many psychoanalysts as being than past experience. too behavioural and distant from the inner worlds of their patients, so that until relatively recently The influence of attachment style on process and psychoanalysis and attachment theory developed outcome in parallel (Levy 2012). Furthermore, studies have demonstrated that a Bowlby’s hypothesis that the earliest attachment patient’s attachment organisation may influence experiences between the child and its caregivers the treatment trajectory by acting as a moderator of fundamentally shape the personality and have both psychotherapy process and outcome, findings long-lasting effects on adult mental health and which hold prognostic implications for treatment. psychopathology have been validated by empirical For example, patients with avoidant attachment research. Bowlby (1969, 1973, 1977) believed that status find it more difficult to form a therapeutic the child’s primary caregivers’ style of relating and alliance, but if they can be engaged tend to benefit responding lead to the development of different from treatment (Fonagy 1996). This underscores patterns of attachment in the child, which in the importance of actively fostering the treatment turn form ‘internal working models’ that guide alliance as early as possible in the patient’s the child’s perceptions, emotions, thoughts and care. Therapeutic outcome can be measured expectations in later relationships. This hypothesis by observing shifts in the patient’s attachment was initially developed into observational research patterns towards a more secure organisation over with Ainsworth’s (1978) classification of different the course of psychotherapy (Levy 2006). infant behavioural attachment patterns in Moreover, the therapist’s own attachment response to the ‘strange situation’. Infants with organisation has been shown to have a significant insecure attachment patterns were found more impact on the outcome of the patient’s therapy. likely to experience greater psychopathology As one might expect, therapists who are and difficulties in interpersonal relationships in securely attached achieve the best therapeutic adulthood (Berlin 2008). Main and others extended results (Dozier 1994), but studies also show that Ainsworth’s findings to measuring adult mental matching of specific attachment styles between representations of attachment with the Adult therapist and patient predicts psychotherapy Attachment Interview (AAI) (Main 1985). They process and outcome. For example, patients showed that the representations of an adult parent’s who have a therapist who is opposite to them own attachment experiences have significant on the ‘preoccupying to dismissing’ dimension influence on their children’s development and of attachment on the AAI tend to have better attachment patterns, which determine the child’s outcomes than patient–therapist pairs who do not later socioemotional functioning in adulthood. (Levy 2012). This has implications regarding the

Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 275 Yakeley

selection and assessment of the interpersonal style Box 4 Outcome measures used in psycho­ of therapists for training in psychotherapy. dynamic psychotherapy research Attachment theory-based interventions Adult Attachment Interview (AAI) (George 1996): a semi- Certain specific psychodynamic psychotherapies, structured interview measuring attachment organisation such as interpersonal therapy (Klerman 1996), Clinical Outcomes in Routine Evaluation Outcome transference-focused psychotherapy (Clarkin Measure (CORE-OM) (Evans 2000): a patient-rated 2006; Kernberg 2008) and mentalisation-based questionnaire of psychological distress therapy (Bateman 2004, 2006), have developed as Defense Mechanism Rating Scale (DMRS) (Perry 1990): explicitly attachment theory-based interventions, an observer-rated measure of psychological defences conceptualising and measuring change in terms of Reflective Functioning Scale (RFS) (Fonagy 1998): a scale attachment representations and developing specific used in conjunction with the AAI to measure reflective or techniques designed to target the attachment mentalisation capacity system (Table 1). Shedler–Westen Assessment Procedure – 200 (SWAP- However, one could argue that attachment 200) (Westen 1999): a clinician-rated assessment theory implicitly guides all psychotherapies. measure of personality psychopathology and health Fonagy and others suggest that improving the patient’s capacity for mentalisation or self-reflective functioning, which is dependent on the person’s that occur in the patient–therapist relationship early developmental attachment experiences, is reactivate attachment processes in the patient, a key component of all psychotherapies. They particularly regarding issues of relatedness and self- propose that dysfunctional mentalisation is an definition. The therapeutic relationship alternates essential feature of all psychological disorders, between cycles of disruption and repair, reactivating and that psychological therapies improve experiences of compatibility and incompati­ mentalisation by changing underlying neuronal bility at various developmental stages. These are structures in different parts of the brain that gradually explored, using the transference and regulate the experience of the self (Fonagy 2012). countertransference as guiding tools, to facilitate their integration into new representations of self Towards a new paradigm and others and the development of more mature Luyten et al (2012) argue for a new paradigm mental reflective capacities and differentiated within psychodynamic treatment research, away relationships. Although maintaining an overall from assumptions borrowed from pharmaceutical positive therapeutic alliance with a warm and trials in which outcomes are based on simple empathic therapist is essential, negative reactions observable features such as symptom improvement based on transference-derived distortions of and in which simple linear causal models are the therapeutic relationship are inevitable, and used to predict process–outcome relationships, should be allowed to develop before addressing towards a broader paradigm that investigates underlying issues. Premature repair of negative less observable underlying personality changes transference experiences has been shown to and does not assume that such changes occur hamper, rather than facilitate, the therapeutic in a linear fashion. Such a paradigm is better process (Kachele 2009). suited to investigating the more fundamental non- Although a full discussion is beyond the scope of linear processes that may occur in longer-term this article, this model of psychodynamic psycho­ treatments, such as changes in affect regulation, therapy is supported by a deepening under­standing enhanced capacity for self-reflection, and changes of the neurobiological underpinnings of attachment in the representation of self and others. Capturing and interpersonal relationships, as part of a fertile such intrapsychic changes will necessitate intersection of contemporary neuroscience and the development and implementation of more psychodynamic psycho­therapy research. sophisticated measures, a number of which have been validated and used to study the process and Transdiagnostic­ treatments outcome of psychodynamic psychotherapy (Box 4). Psychotherapy research is moving from single- disorder focused manualised approaches towards Psychodynamic therapy as a developmentally ‘transdiagnostic’ and modular treatments. informed dynamic process These focus on similarities between disorders, In this model, psychodynamic therapy may be particularly those in a similar diagnosis class viewed as a developmentally informed dynamic which include high rates of comorbidity (e.g. process in which the interpersonal interactions anxiety disorders), so that improvements are seen

276 Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 Psychodynamic psychotherapy: developing the evidence base

in the comorbid conditions when treating the therapy for mood disorders, has been rolled principal disorder (Leichsenring 2014). out nationally within IAPT services as the Trans­diagnostic treatment protocols have been brief psychodynamic model for the treatment pioneered by researchers in the field of CBT (e.g. of depression. The DIT treatment protocol Barlow 2004; Norton 2008; McHugh 2009), but emerged from the work of an expert reference psychodynamic psychotherapy may be particularly group on clinical competencies which identified suited to this approach as it is traditionally less and distilled the key therapeutic components tailored to single mental disorders, but focuses drawn from manualised psychoanalytic/dynamic on the core underlying processes of mental therapies with the strongest empirical evidence for conditions, including psychotic illnesses. Newer efficacy, and is therefore an excellent example of conceptualisations of schizophrenia and other an evidence-based, collaboratively designed and psychoses, and their treatments, are based on tested psychodynamic intervention. attachment theory and mentalising (Lysaker However, the provision of longer-term psycho­ 2013; Rosenbaum 2013) and although RCTs of dynamic therapies is becoming increasingly scarce psychodynamic psychotherapy in schizophrenia within the public sector, despite evidence that are lacking, promising research by groups such they may provide enduring positive outcomes in as the Danish National Schizophrenia Project both symptom reduction and personality change. (Rosenbaum 2012) strengthens the evidence for It remains our responsibility to ensure that such the effectiveness of psychodynamic treatment evidence is fairly and openly communicated to in psychosis. commissioners and policy makers so that psycho­ dynamic psychotherapies retain a legitimate place Implications for practice within the choice of evidence-based treatments available for our patients. Psychodynamic psychotherapists themselves, in their failure to fully embrace an evidence- References based approach and be open to adaptation of their concepts and techniques in the light of Abbass AA, Hancock JT, Henderson J, et al (2006) Short-term psycho­ dynamic psychotherapies for common mental disorders. Cochrane empirical findings, must bear some responsibility Database of Systematic Reviews, 4: CD004687. for the perception that the therapy they practise Abbass A, Kisely S, Kroenke K (2009) Short-term psychodynamic is ineffective. Moreover, the expanding array psychotherapy for somatic disorders: systematic review and meta- of different therapeutic modalities risks being analysis of clinical trials. Psychotherapy and Somatics, 78: 265–74. satirised as a collection of competing brands Ainsworth MS, Blehar MC, Waters E, et al (1978) Patterns of Attachment: promoted by their charismatic inventors, which A Psychological Study of the Strange Situation. Lawrence Erlbaum Associates. may obscure more serious and collaborative Barlow DH, Allen LB, Choate ML (2004) Toward a unified treatment for efforts to find common therapeutic techniques emotional disorders. Behavior Therapy, 35: 205–30. and factors, as well as factors more specific to Bateman A, Fonagy P (2004) Psychotherapy for Borderline Personality particular psychic processes or pathological Disorder: Mentalization-Based Treatment. Oxford University Press. conditions. Bateman A, Fonagy P (2006) Mentalization-Based Treatment for Border­ Nevertheless, the scientific evidence summar­ line Personality Disorder: A Practical Guide. Oxford University Press. ised here should dismantle the myth that psycho­ Berlin LJ, Cassidy J, Appleyard K (2008) The influence of early dynamic approaches lack empirical support, a myth attachments on other relationships. In Handbook of Attachment: Theory, Research and Clinical Applications (eds J Cassidy, PR Shaver): 333–47. that may reflect selective dissemination of robust Guilford Press. research findings (Shedler 2010). These findings Blagys M, Hilsenroth M (2000) Distinctive features of short-term provide evidence to show that psychodynamic psychodynamic-interpersonal psychotherapy: a review of the comparative treatments are effective for a wide range of mental psychotherapy process literature. Clinical Psychology: Science and Practice, 7: 167–88. disorders, and challenge the current trend for a psychodynamic approach to be solely located Bowlby J (1969) Attachment and Loss: Vol 1, Attachment. Basic Books. in specialised personality disorder services Bowlby J (1973) Attachment and Loss: Vol 2, Separation, Anxiety and Anger. Basic Books. rather than available in generic mental health Bowlby J (1977) The making and breaking of affectional bonds. I. or psychological services treating more common Aetiology and psychopathology in the light of attachment theory. British mental disorders such as anxiety and depression. Journal of Psychiatry, 130: 201–10. This evidence also underscores the importance of British Psychoanalytic Council, UK Council for Psychotherapy (2013) experience in psychodynamic psychotherapy as Quality Psychotherapy Services in the NHS: Summary Findings from part of the training of all psychiatrists. the UK Council for Psychotherapy and British Psychoanalytic Council Members’ Survey. BPC/UKCP. It is therefore encouraging that dynamic Clarkin JF, Yeomans FE, Kernberg OF (2006) Psychotherapy for Borderline interpersonal therapy (DIT) (Lemma 2012), a Personality: Focusing on Object Relations. American Psychiatric simple short-term individual psychodynamic Association.

Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 277 Yakeley

Connolly MB, Crits-Christophe P, Shappel S, et al (1999) Relations of Leichsenring F, Rabung S (2008) Effectiveness of long-term psychodynamic MCQ answers transference interpretations to outcome in the early sessions of brief psychotherapy. JAMA, 300: 1151–65. supportive-expressive psychotherapy. Psychotherapy Research, 9: 1 d 2 c 3 e 4 a 5 c Leichsenring F, Rabung S (2009) Analyzing effectiveness of long-term 485–95. psychodynamic psychotherapy reply. JAMA, 301: 932–3. de Maat S, de Jonghe F, Schoevers R, et al (2009) The effectiveness of Leichsenring F, Klein S (2014) Evidence for psychodynamic psychotherapy long term psychoanalytic psychotherapy: a systemic review of empirical in specific mental disorders: a systematic review. Psychoanalytic studies. Harvard Review of Psychiatry, 17: 1–23. Psychotherapy, 28: 4–32. Department of Health (2007) Commissioning a Brighter Future: Improving Access to Psychological Therapies. Department of Health. Lemma A, Target M, Fonagy P (2010) The development of a brief psychodynamic protocol for depression: Dynamic Interpersonal Therapy Dozier M, Cue KL, Barnett KL (1994) Clinicians as caregivers: role of (DIT). Psychoanalytic Psychotherapy, 24: 329–46. attachment organization in treatment. Journal of Consulting and Clinical Psychology, 62: 793–800. Lemma A, Target M, Fonagy P (2012) Brief Dynamic Interpersonal Therapy: A Clinician’s Guide. Oxford University Press. Evans C, Mellor-Clark J, Margison F, et al (2000) CORE: Clinical Outcomes in Routine Evaluation. Journal of Mental Health, 9: 247–55. Levy KN, Meehan KB, Kelly KM, et al (2006) Change in attachment patterns and reflective function in a randomized control trial of Fonagy P, Leigh T, Steele M, et al (1996) The relation of attachment transference-focused psychotherapy for borderline personality disorder. status, psychiatric classification and response to psychotherapy. Journal Journal of Consulting and Clinical Psychology, 74: 1027–40. of Consulting and Clinical Psychology, 624: 22–31. Levy KN, Meehan KB, Temes CM, et al (2012) Attachment theory Fonagy P, Target M, Steele H, et al (1998) Reflective Functioning Manual and research: implications for psychodynamic psychotherapy. In . University Version 5.0 for Application of Adult Attachment Interviews Psychodynamic Psychotherapy Research: Evidence-Based Practice and College London. Practice-Based Evidence (eds RA Levy, JS Ablon, H Kachele): 401–16. Fonagy P, Adshead G (2012) How mentalisation changes the mind. Humana Press. Advances in Psychiatric Treatment, 18: 353–62. Luborsky L, Singer B, Luborsky L (1975) Comparative studies of Gabbard GO (2004) Long-Term Psychodynamic Psychotherapy: A Basic psychotherapies. Is it true that “everyone has won and all must have Text. American Psychiatric Publishing Inc. prizes”?Archives of General Psychiatry, 32: 995–1008. George C, Kaplan N, Main M (1996) The Adult Attachment Interview Luyten P, Blatt SJ, Mayes LC (2012) Process and outcome in (3rd edn). Department of Psychology, University of California, Berkeley. psychoanalytic psychotherapy research: the need for a (relatively) new Gerber AJ, Kocsis JH, Milord BL, et al (2010) A quality-based review of paradigm. In Psychodynamic Psychotherapy Research: Evidence-Based randomized controlled trials of psychodynamic psychotherapy. American Practice and Practice-Based Evidence (eds RA Levy, JS Ablon, H Kachele): Journal of Psychiatry, 168: 19–28. 345–59. Humana Press. Guthrie E, Creed F, Dawson D, et al (1991) A controlled trial of psychological Lysaker PH, Buck KD, Fogley RL, et al (2013) The mutual development treatment for the irritable bowel syndrome. Gastroenterology, 100: 450–7. of intersubjectivity and metacognitive capacity in the psychotherapy for persons with schizophrenia. Journal of Contemporary Psychotherapy, 43: Guthrie E (1999) Psychodynamic interpersonal therapy. Advances in 63–72. Psychiatric Treatment, 5: 135–45. Main M, Kaplan N, Cassidy J (1985) Security in infancy, childhood and Hilsenroth MJ, Cromer TD, Ackerman SJ (2012) How to make practical adulthood: a move to the level of representation. Monographs of the use of therapeutic alliance in your clinical work. In Psychodynamic Society for Research in Child Development, 50: 66–104. Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence (eds RA Levy, JS Ablon, H Kachele): 361–80. Humana Press. Malan DH (1976) Toward the Validation of Dynamic Psychotherapy. Plenum. Hobson RF (1985) Forms of Feeling: The Heart of Psychotherapy. Basic Books. Marziali EA (1984) Prediction of outcome of brief psychotherapy from therapist interpretive interventions. Archives of General Psychiatry, 41: Høglend P (1993) Transference interpretations and long-term change 301–4. after dynamic therapy of brief to moderate length. American Journal of Psychotherapy, 47: 494–507. McHugh RK, Murray HW, Barlow DH (2009) Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: Høglend P, Bøgwald KP, Amlo S, et al (2008) Transference interpretations the promise of transdiagnostic interventions. Behaviour Research and in dynamic psychotherapy: do they really yield sustained effects? Therapy, 47: 946–53. American Journal of Psychiatry, 165: 763–71. Høglend P, Gabbard GO (2012) When is transference work useful in Norton PJ, Phillip LM (2008) Transdiagnostic approaches to the treatment psychodynamic psychotherapy? A review of empirical research. In of anxiety disorders: a quantitative review. Psychotherapy: Theory, Psychodynamic Psychotherapy Research: Evidence-Based Practice and Research, Practice, Training, 45: 214–26. Practice-Based Evidence (eds RA Levy, JS Ablon, H Kachele): 449–67. Ogrodniczuk JS, Piper WE, Joyce AS, et al (1999) Transference Humana Press. interpretations in short-term dynamic psychotherapy. Journal of Nervous Kachele H, Schacter J, Thoma H (2009) From Psychoanalytic Narrative to and Mental Disease, 187: 572–9. Empirical Single Case Research: Implications for Psychoanalytic Practice. Perry JC (1990) Defense Mechanism Rating Scales (DMRS) (5th edn). Routledge. Cambridge MA, published by author. Kernberg OF, Yeomans FE, Clarkin JF, et al (2008) Transference Perry JC, Petraglia J, Olson TR, et al (2012) Accuracy of defense focused psychotherapy: overview and update. International Journal of interpretation in three character types. In Psychodynamic Psychotherapy Psychoanalysis, 89: 601–20. Research: Evidence-Based Practice and Practice-Based Evidence (eds RA Klerman GL, Weissma MW, Rounsaville BJ, et al (1996) Interpersonal Levy, JS Ablon, H Kachele): 417–47. Humana Press. Psychotherapy of Depression. Jason Aronson. Piper WE, Delbane EG, Bienvenu J-P, et al (1986) Relationships between Leichsenring F, Leibing E (2003) The effectiveness of psychodynamic the object focus of therapist interpretations and outcome of short-term therapy and cognitive therapy in the treatment of personality disorders: individual psychotherapy. British Journal of Medical Psychology, 59: a meta-analysis. American Journal of Psychiatry, 160: 1223–32. 1–11. Leichsenring F, Rabung S, Leibing E (2004) The efficacy of short-term Piper WE, Azim HF, Joyce AS, et al (1991) Transference interpretations, psychodynamic psychotherapy in specific psychiatric disorders: a meta- therapeutic alliance and outcome in short-term individual therapy. analysis. Archives of General Psychiatry, 61: 1208–16. Archives of General Psychiatry, 48: 946–53.

278 Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 Psychodynamic psychotherapy: developing the evidence base

Rosenbaum B, Harder S, Knudsen P, et al (2012) Supportive psychodynamic Ryle A (1982) Psychotherapy: A Cognitive Integration of Therapy and psychotherapy versus treatment as usual for first episode psychosis: Practice. Academic Press. two-year outcome. Psychiatry: Interpersonal and Biological Processes, Ryle A (1990) Cognitive Analytic Therapy: Active Participation in Change. 75: 331–41. John Wiley & Sons. Rosenbaum B, Martindale B, Summers A (2013) Supportive Shedler J (2010) The efficacy of psychodynamic psychotherapy. American psychodynamic psychotherapy for psychosis. Advances in Psychiatric Psychologist, 65: 98–109. Treatment, 19: 310–8. Westen D, Shedler J (1999) Revising and assessing Axis II. Part 1: Rosenzweig S (1936) Some implicit common factors in diverse methods of Developing a clinically and empirically valid assessment method. psychotherapy. American Journal of Orthopsychiatry, 6: 412–5. American Journal of Psychiatry, 156: 258–72. Rosser R, Denford J, Heslop A, et al (1983) Breathlessness and Yakeley J, Adshead G (2013) Locks, keys and security of mind: psychiatric morbidity in chronic bronchitis and emphysema: a study of psychodynamic approaches to forensic psychiatry. Journal of the psychotherapeutic management. Psychological Medicine, 13: 93–110. American Academy of Psychiatry and the Law, 41: 38–45.

MCQs d the number of RCTs of psychodynamic b the patients of therapists who are measured as Select the single best option for each question stem psycho­­therapy is much smaller than that for having secure attachments on the AAI tend to cognitive–behavioural therapy have better outcomes 1 Which of the following features is not e effect sizes for longer-term psychodynamic c attachment research has provided empirical characteristic of contemporary psycho­ psychotherapy are higher than those for the evidence validating the concept of transference dynamic psychotherapy technique? shorter-term therapies. d therapeutic outcome can be measured by a focus on emotion and affect observing changes in the patient’s attachment b exploration of significant events in childhood status c transference interpretations 3 Which therapist techniques are associated e attachment theory may provide a framework d setting goals with positive outcome? for non-psychodynamic treatments. e use of countertransference. a early repair of negative transference experiences 5 Available evidence suggests that best 2 Which of the following is not true b high rate of transference interpretations regarding outcome studies of psycho­ therapeutic practice involves: c early interpretation of unconscious fantasies a proliferation of new therapeutic modalities dynamic psychotherapy? d self-disclosure a effect sizes for psychodynamic psychotherapy b cutting traditional psychodynamic psycho­ e early fostering of positive therapeutic therapy services are as large as those reported for cognitive– alliance. behavioural therapy c receiving treatment from a warm and empathic b better designed studies include manualisation therapist d shorter-term therapies of the treatment intervention 4 Which of the following is not true of e the therapist’s self-disclosure. c process–outcome studies show that the attachment theory? efficacy of psychodynamic psychotherapy is a attachment theory explicitly underpins most likely due to ‘common factors’ cognitive analytic therapy

Advances in psychiatric treatment (2014), vol. 20, 269–279 doi: 10.1192/apt.bp.113.012054 279