Contemporary approaches to time-limited psychodynamic psychotherapy with adults
In Shedler’s (2010) landmark research analysis on ‘The Efficacy of Psychodynamic Psychotherapy’, he makes the point that effect sizes for psychodynamic psychotherapy are as large as those reported for other therapies. He refers to the study by Abbass, Hancock, Henderson and Kisely (2006) which utilised a methodologically rigorous metaanalysis of psychodynamic therapy published by the Cochrane Library. The studies which compared patients with a wide range of mental disorders (depression, anxiety, somatic symptoms) who received time-limited psychodynamic psychotherapy of 40 hours, with controls consisting of a waiting list, minimal intervention or
‘treatment as usual’ showed positive findings with respect to reduction of symptoms. In addition, these improvements had increased at longterm follow-up. Shedler quotes similar results of a meta-analysis (Leichsenring, Rabung and Leibing, 2004) published in the Archives of General Psychiatry which indicates the positive clinical results in 17 ‘high quality’ randomised controlled trials of time-limited psychodynamic psychotherapy where the average number of sessions was 21.
However, the challenges presented by the randomised controlled trial as the gold standard of evidence-based practice, pose a particular problem for psychodynamic psychotherapy. As Shedler states, the goal of the therapy is not simply symptom remission for the patient, but the development of psychological capacities that are intrinsically associated with ‘self-reflection’ and ‘self-discovery’. Both self-reflection and selfdiscovery are perceived by psychodynamic psychotherapists as contributing to long-term psychological health. These reservations are echoed by Alessandra Lemma, Mary Target and Peter Fonagy (2011) in their discussion of their model of time-limited adult psychotherapy known as Dynamic Interpersonal Therapy (DIT). They make the point that whilst evidence-based practice remains a requirement as the primary driver of contemporary healthcare, the self-limiting nature of what is deemed to be evidence does not take into account the complexity of lived experience, particularly with respect to what constitutes wellbeing.
There is further disquiet concerning the fact that the ‘gold standard’ of the RCT may be somewhat overvalued given the information that is increasingly coming to light about how large-scale funded studies specifically into drug treatments, are silent about their ‘null findings’ (Rawlins, 2008). A further factor as Lemma et al. point out, is that most evidence-based research does not create a space for patient participation. This in effect limits our knowledge about what is actually happening for the distressed patient and how to evaluate which treatments may contribute to their wellbeing (Dolan, 2008). In their 2011 paper Lemma et al. describe a pilot study involving the treatment of 16 depressed patients as a prelude to a future larger scale randomised controlled trial. In the pilot study, DIT was associated with a significant reduction in reported symptoms. The protocol developed by Lemma et al. (2011) is closely aligned with a set of competencies that specify the training requirements and skills required to work effectively with DIT, with the aim of creating a coherent practice manual that can be utilised by practitioners trained in psychodynamic psychotherapy. As the authors explain, their aim is not to invent a new model of psychodynamic therapy, but rather to provide a pragmatic model for time-limited psychotherapy with primarily anxious and depressed patients. The authors confirm that therapists experienced in long-term work cannot ‘simply export’ the techniques and framework of long-term work to time-limited therapy.
The following chapter will review some of the current research in time-limited psychotherapy with respect to children and adolescents.