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 develop ments 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and Psychodynamic psychotherapy has been research that go some way in refuting these criticised as being based on outdated principles of Director of Medical Education criticisms.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 well­designed 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: jyakeley@tavi­port.nhs.uk psycho dynamic 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 longer­term treatments by experience of both the social world and the highly trained pro fessionals 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 ‘evidence­based’ 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). psycho dynamic psycho therapy 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 psycho dynamic 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 time­limited, 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