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Psychodynamic Psychiatry, 42(3) 377–422, 2014
© 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry
Kenneth N. Levy, Ph.D., Associate Professor, Department of Psychology, Pennsylvania
State University; Adjunct Assistant Professor, Department of Psychiatry, Weill Medical
College of Cornell University.
Johannes C. Ehrenthal, Ph.D., Department of General Internal Medicine and
Psychosomatics, University of Heidelberg.
Frank E. Yeomans, M.D., Ph.D., Clinical Associate Professor, Weill Medical College
of Cornell University; Adjunct Clinical Professor of Psychiatry, Columbia University
College of Physicians and Surgeons.
Eve Caligor, M.D., Clinical Professor of Psychiatry, Columbia University College of
Physicians and Surgeons.
The authors would like to thank Richard Friedman for comments on an earlier version
of the article as well as the comments and guidance provided by the members of The
Committee on Psychotherapy of the Group for the Advancement of Psychiatry: Stephan
Bauer, M.D., Meiram Bendat, J.D., M.F.T., Norman Clemens, M.D., Jerold Kay, M.D.,
Susan G. Lazar, M.D., Kenneth N. Levy, Ph.D., Michael Myers, M.D., John Oldham, M.D.,
Eric Plakun, M.D., Lisa Mellman, M.D., William Sledge, M.D., and Frank E. Yeomans,
M.D. Dr. Levy acknowledges the support and funding provided while serving as an
Ittleson Fellow. Finally, we acknowledge Allyssah Aldinger and Jacqueline V. Proszynski
for their assistance in preparing the article.
LEVY ET AL.
EFFICACY OF PSYCHOTHERAPY
The Efcacy of Psychotherapy: Focus on
Psychodynamic Psychotherapy as an Example
Kenneth N. Levy, Johannes C. Ehrenthal, Frank E. Yeomans,
and Eve Caligor
Abstract: The growing number of individuals seeking treatment for mental
disorders calls for intelligent and responsible decisions in health care politics.
However, the current relative decrease in reimbursement of effective psycho-
therapy approaches occurring in the context of an increase in prescription of
psychotropic medication lacks a scientific base. Using psychodynamic psycho-
therapy as an example, we review the literature on meta-analyses and recent
outcome studies of effective treatment approaches. Psychodynamic psycho-
therapy is an effective treatment for a wide variety of mental disorders. Add-
ing to the known effectiveness of other shorter treatments, the results indicate
lasting change in many cases, especially for complex and difficult to treat pa-
tients, ultimately reducing health-care utilization. Research-informed health
care decisions that take into account the solid evidence for the effectiveness of
psychotherapy, including psychodynamic psychotherapy, have the potential to
promote choice, increase mental health, and reduce society’s burden of disease
in the long run.
378 LEvY ET AL.
With the advent of the Affordable Care Act and the focus on parity
in the provision of mental health care, it is more important than ever
to understand the evidence base for mental health treatments for the
various types of psychological and psychiatric difficulties from which
many Americans suffer. We suggest that it is incumbent for all stake-
holders—government agencies that fund and supplement the provi-
sion treatment; public and private insurance companies that fund and
reimburse treatments; patients and families that consume and pay for
mental health services, and clinicians that provide such services—to be
familiar with the evidence base supporting the efficacy of a full range
of mental health interventions. In this article we review the extensive
evidence for the usefulness of psychotherapy as a central and impor-
tant treatment modality for a range of mental health problems and dis-
orders.
In the United States, 31% of the population is affected by mental
health problems every year; however, 67% do not receive treatment
(Kessler et al., 2005). This discrepancy between those in need of mental
health services and those who receive them is known as the “service
gap” or “treatment gap.” Although mental health treatment utilization
has increased over recent years, this increase has been accounted for by
increased rates of patients receiving pharmacotherapy (Olfson & Mar-
cus, 2009, 2010). At the same time, there is much evidence that the use
of psychotherapy is on the decline. For example, although the percent-
age of people in the United States receiving outpatient psychotherapy
has remained relatively steady over the years (3.37% in 1998, 3.18% in
2007), the use of psychotherapy as a sole intervention (15.9% to 10.5%)
and psychotherapy prescribed in conjunction with medication (40% to
32.1%) have steadily decreased while the rate of medication prescribed
alone (44.1% to 57.4%) has steadily increased (Olfson & Marcus, 2010;
Olfson, Marcus, Druss, & Pincus, 2002). The average number of psy-
chotherapy visits also has decreased over time, and fewer psychia-
trists are delivering psychotherapy (Akincigil et al., 2011; Mojtabai &
Olfson, 2008a). This decrease in the number of outpatients receiving
psychotherapy and the increase in the number of outpatients receiving
medication is in direct opposition to studies that report clear preference
for psychotherapy over medications for many patients and families.
For example, studies consistently show that patients, particularly de-
pressed ones, prefer psychotherapy to medication (McHugh, Whitton,
Peckham, Welge, & Otto, 2013; Prins et al., 2008; van Schaik et al., 2004).
Patient and family preferences aside, decisions about treatment in-
terventions should be driven by the best evidence available. Thus it is
surprising that this increase in the use of medications and decrease in
the provision of psychotherapy is inconsistent and in direct contrast
EFFICACY OF PSYCHOTHERAPY 379
with the evidence base and often leads to questionable practice. For ex-
ample, antidepressants are often prescribed for subthreshold or lower
levels of depression when effect sizes are lower for the use of medi-
cation alone in such depressions and psychotherapy is the preferable
first-line treatment (Antonuccio, Danton, & DeNelsky, 1995; Persons,
Thase, & Crits-Chrstoph, 1996; Wexler & Cicchetti, 1992).1
While the decline in psychotherapy utilization no doubt reflects
many factors (e.g., increasing medicalization, direct-to-consumer ad-
verting of psychotropic drugs, increasing emphasis on short-term vs.
long-term outcomes), restrictions in insurance reimbursements for
psychotherapy have played and an important role in psychotherapy
delivery in the U.S. Insurance reimbursement practices frequently pro-
vide financial disincentives for providing psychotherapy as compared
to the incentives for providing psychotropic medications (Mojtabai &
Olfson, 2008a). For example, psychotherapy reimbursement rates have
decreased over recent decades (Frank, Goldman, & McGuire, 2009; Ru-
pert & Baird, 2004) while psychiatrists can bill three or four patients
for 15-minute medication checks within the same time frame as the
typical hour needed for a psychotherapy session. As a result rates of
depression treatment by, for example, psychologists have decreased
(Rupert & Baird, 2004), and fewer and fewer psychiatrists are provid-
ing psychotherapy (Druss, 2010; Mojtabai & Olfson, 2008a). At the same
time treatment of psychological conditions by primary care physicians
has increased (Mojtabai & Olfson, 2008b; Olfson et al., 2002). Primary
care physicians, despite best intentions to help their patients, receive
only 6 weeks of psychiatry training during medical school, generally
do not receive training in psychosocial interventions, and thus rarely
offer such options to their patients despite the evidence of the efficacy
and cost-effectiveness of such treatments (Antonuccio et al., 1995; Heu-
zenroeder et al., 2004; Spielmans, Berman, & Usitalo, 2011; Vos et al.,
2005). In contrast, in the United Kingdom and many other European
countries treatment guidelines such as the U.K.’s National Institute for
Health and Clinical Excellence (www.nice.org.uk) place greater value
1. At the same time, psychotropic medication is increasingly prescribed by primary
care physicians instead of psychiatrists, further increasing the noted disparity as the
former cannot provide psychotherapy (Mojtabai & Olfson, 2010). This is even more
relevant when taking into account that psychopharmacological interventions have
to be monitored carefully due to their potential of somatic side effects (e.g., De Hert,
Detraux, van Winkel, Yu, & Correll, 2011). In everyday practice there is a growing trend
for polypharmacy with poor risk-benefit ratios, off-label use of antipsychotic medication,
for example for the treatment of anxiety syndromes (Comer, Mojtabai, & Olfson, 2011),
and the widespread dissemination of medication whose long-term effects have not been
adequately understood, for example concerning amphetamine-based stimulants for
children with a diagnosis of ADHD.
380 LEvY ET AL.
on the provision of psychosocial treatments as first line treatments for
many psychological and psychiatric conditions (Clark, 2011; Richards
& Borglin, 2011).
Following the emphasis on psychosocial treatments in the U.K. and
Europe, the underutilization of psychotherapy has been recognized,
leading to government-based intervention to improve access. For ex-
ample, the U.K. government initiated a program called Improving Ac-
cess to Psychological Therapies (IAPT) for depression and anxiety. This
program was aimed at training 6,000 therapists over a six-year period
beginning in 2008 in order to increase access for one million people.
The Swedish government also embarked on an equally ambitions shift
in order to remedy the underprovision in psychotherapy for treating
psychological problems (Holmqvist, Ström, & Foldemo, 2014). Efforts
of this kind have been sorely lacking in the U.S. healthcare system
The declining utilization of psychotherapy in the U.S. is unfortunate
from the perspective of our patients, who could benefit from the many
evidence-based psychotherapeutic interventions available, but also
from the perspective of long-term expenditures, especially in relation
to chronic complex mental disorders such as personality disorders,
which profit preferentially from psychotherapeutic intervention—often
in conjunction with medication management. Declining utilization of
psychotherapy in the U.S. is not at all warranted by the data on out-
come. Despite common misconceptions, there is a vast evidence base
for the efficacy of different forms of psychotherapy for a wide spectrum
of disorders with effects that are as strong as or stronger than those of
medication and without the serious side effects often found with medi-
cation use.
In this article we provide an overview of some of these outcome data.
We focus on outcome of psychodynamic interventions, where negative
bias in the field is most pronounced (Levy & Anderson, 2013). Many
clinicians and academicians in psychiatry and psychology believe
that psychodynamic treatments have either (1) not been tested or (2)
that they have been found to be less effective than other treatment ap-
proaches. Although it is true that psychoanalytic and psychodynamic
psychotherapies possess a smaller research base than some other ap-
proaches such as cognitive behavioral (CBT), there currently exists a
strong literature on the efficacy of psychodynamic therapies (PDT) for
a variety of acute and chronic mental disorders. We also focus on PDT
as a case study of the misconception that psychotherapies do not have
an evidence base. The reader keeps in mind that there is an equally
strong or larger database for cognitive behavioral treatments and inter-
personal psychotherapy (considered by some a PDT treatment; Crits-
Cristoph, 1992) and emotion-focused treatments. Additionally, there
EFFICACY OF PSYCHOTHERAPY 381
is a growing evidence base for humanistic and existential based treat-
ments. Similarities and differences between these various treatment ap-
proaches will be briefly described in the next section.
wHAT IS PSYCHOTHERAPY?
“What is therapy?”; “What is the evidence for its efficacy?”; and
“How should practitioners across all professions be trained?” These
questions are essential with regard to this core clinical activity of psy-
chiatrists, psychologists, social workers, and other mental health care
professionals (Weissman et al., 2006). “Psychotherapy” can perhaps
best be thought of as a plural noun given the many types and various
levels of intervention by which it can be defined. For our purposes, we
broadly define psychotherapy as a series of interrelated techniques or
interventions designed to ameliorate mental health, emotional, behav-
ioral, psychological, and/or psychiatric disorders based primarily on
the verbal and/or nonverbal communication with an identified thera-
pist or practitioner with an identified patient.2
The most well-known individual psychotherapies include cognitive
behavioral therapy (CBT), behavioral therapy (BT), psychodynamic
therapy (PDT), the latter including expressive, supportive, and depth
PDTs, psychoanalysis (PSA), interpersonal therapy (IPT), Gestalt, Hu-
manistic/Existential, experiential, client-centered (CCT), and deriva-
tive therapies such as emotion focused therapy. Within each of these
modalities therapy can be conceptualized as long-term (e.g., one or
more years with sessions; one or more times a week), or short-term
(e.g., 6, 12, 16, or 24 sessions, usually once per week). BTs are based on
the application of learning principles, the influence of reinforcement,
and behavioral patterns and tend to avoid focusing on cognition, be it
conscious or unconscious, although in recent years there has been more
focus among BT therapists on integrating these types of processes (see
Levy & Anderson, 2013). CBT techniques utilize learning principles,
but in the context of conscious thought processes, particularly those
that may be distorted (e.g., “I have to be excellent at everything I do
or I am a failure”), and may lead to feelings of depression, anxiety, or
2. The words client, patient, and consumer are used differentially by various professional
groups that provide treatment to refer those individuals who receive psychotherapy. In
this article, we use the convention of patient. All three terms infer a relationship with
another: a client is under the protection or receiving professional advice from an advisor;
a patient is suffering from an illness and receives care from a doctor; a consumer buys
services from his or her insurance plan and a managed care provider.
382 LEvY ET AL.
both. CBT treatments tend to teach patients skills and the use of home-
work assignments, like in BT, tends to take a more didactic stance. In
contrast, humanistic/existential/CCT and PDT treatments are usually
more conversational, focusing on fears, emotion, and unconscious in-
fluences. BT and CBT therapies tend to be brief (e.g., 6 to 16 weeks),
although there is some evidence that many BT and CBT therapies are
practiced long term in the community (Gillespie, Duffy, Hackmann, &
Clark, 2002; McKay, Nudelman, McCadam, & Gonzales, 1996; Thomp-
son-Brenner & Westen, 2005; Westen & Morrison, 2001) and that BT and
CBT treatments for more severely disturbed patients such as person-
ality disordered ones are typically conceptualized as long term (Beck,
Freeman, Davis, & Associates, 2004; Linehan, 1993). In contrast PDTs
tend to be longer term, although there are now a number of short-term
or brief PDTs available (Abbass, Sheldon, Gyra, & Kalpin, 2008; Barber,
Muran, McCarthy, & Keefe, 2013; Milrod, Leon, Barber, Markowitz, &
Graf, 2007).
THE NATURE OF EvIDENCE
In order to assess and understand whether or not psychotherapy is
effective and of value, we must examine the nature of evidence. There
should be no disagreement regarding the need for empirical support
for our interventions. There is, however, great disagreement about the
nature and scope of what constitutes evidence. Some have suggested
that randomized controlled trials (RCT), which involve randomizing
patients to two or more treatments, including a placebo condition that
controls for attention and credibility, are the gold standard of evidence.
In fact, some have gone so far as to suggest that RCT is not only the
gold standard, but the lone standard, the only evidence that deserves
consideration. This attitude leads to an implicit but erroneous assump-
tion that the absence of a certain type of evidence proves the lack of
merit in approaches that do not have that level of evidence. At the other
extreme, there are those who point to a number of important critiques
of the RCT design as significant threats to both internal and external
validity. These critics have noted that the controls provided by the RCT
design are confounded by such factors as the use of selected samples
(e.g., those willing to participate in RCTs and the use of limiting in-
clusion and exclusion criteria; Westen, Novotny, & Thompson-Brenner,
2004), non-random dropout (that can invalidate the randomization pro-
cess; Miranda & Borkovec, 1999), lack of treatment fidelity (Ablon &
Jones, 1999), and common factors, therapist factors, and investigator
allegiance effects (Berman & Reich, 2010; Luborsky, Diguer, Seligman,
Rosethal, Krause, Johson et al., 1999; Robinson, Berman, & Neimeyer,
EFFICACY OF PSYCHOTHERAPY 383
1990) as well as other lack of controls (e.g., experiences outside the
consultation room). These investigators often prefer naturalistic stud-
ies that lack randomization as an alternative (Blatt & Zuroff, 2005; Sil-
berschatz’s statement in Persons & Silberschatz, 1998; Stiles, Barkham,
Mellor-Clark, & Connell, 2008). Beutler, Forrester, Gallagher-Thomp-
son, Thompson, and Tomlins (2012) further criticize the standard RCT
model by noting that the use of inclusion and exclusion criteria to cre-
ate a homogenous group of patients, the focus on treatment fidelity and
expert adherent therapists results in a lack of variability, that in turn
reduces variance and the capacity to examine patient, therapist, and
treatment characteristics as moderators of outcome.
Rather than privileging RCTs or naturalistic designs, Levy (Levy,
2012; Levy & Scott, 2007) has argued for a pluralistic approach toward
levels of evidence. RCTs are very valuable, in some ways clearly a gold
standard, but in some ways confounded, as such they are in no way the
lone standard. Rather Levy argued that the juxtaposition and conver-
gence of multiple types and levels of evidence constitute the platinum
standard. The rationale is that each type of evidence speaks to differ-
ent issues.3 Given the different nature of evidence provided by these
different types of studies, there is a need for a diversified portfolio of
evidence in which a variety of methods are juxtaposed against one an-
other in order to protect against the introduction of non-random error.
A convergence of evidence provides reliability and validity of infer-
ences. Thus, to the degree results from experimental/RCT studies are
consistent with data from naturalistic studies, process studies, and ul-
timately meta-analyses, we can be confident of reliable and valid find-
ings. Furthermore, clinical interventions should be consistent with and
related to what is known about developmental psychopathology and
putative mechanisms of change. The true value of evidence is therefore
derived from the convergence between different approaches, which,
when interpreted isolated from other sources, can be problematic (for a
more detailed discussion see Levy & Scott, 2007).
Additionally, important information for clinical practice can be de-
rived from psychopathology, assessment, and epidemiological research
literatures. For example, epidemiological studies have found that per-
sonality disorders are not only prevalent in their own right but are
highly comorbid with other disorders such as mood disorders, anxi-
ety disorders, and substance use disorders (Zanarini et al., 1998). Ad-
ditionally, this comorbidity negatively affects the course and treatment
3. So while the RCT has excellent internal validity it suffers in terms of external validity
and while naturalistic studies have excellent external validity, they suffer in terms of
internal validity.
384 LEvY ET AL.
outcome for these disorders (Newton-Howes, Tyrer, & Johnson, 2006).
Thus, an empirically supported principle is that clinicians should eval-
uate for personality disorders anytime they determine that a patient is
suffering from one of these common comorbid conditions given their
effects on treatment outcome. Second, when interpreting outcome data
it is important to remember that there may be significant but still un-
identified moderators that can influence outcome and would change
our assessment of an intervention and/or provide prescriptive knowl-
edge. For example, in June 2005 the FDA withdrew approval for the use
of Gefitinib due to lack of evidence of its efficacy, however, secondary
moderator analyses found that the medication was more effective for
women and particularly those of Asian descent (Soo et al., 2011). Thus
a medication that appeared inefficacious was highly efficacious for a
subset on individuals. It is quite possible that the same kinds of mod-
erating effects may exist with regard to psychotherapy interventions.
Findings across studies can vary quite a bit. Sometimes this variance
represents random error or variance, while other times it may result
from differences in study design such as sampling, treatment fidelity,
or outcome measurement. For this reason reviews of groups of studies
are important for understanding the broader clinical implications, and
deriving evidence-based principles for clinical decision making. Some
even consider systematic reviews to be the highest level of the evidence
pyramid (Spring & Neville, 2010). One particularly useful method for
systematically reviewing and combining findings across multiple stud-
ies is the use of meta-analysis. For each study the size of the effect or
effect size (ES) is calculated and converted into a common metric to ul-
timately be combined. While in meta-analysis the main focus is on the
direction and magnitude of the effects (ES) across studies, differences
in ES between subgroups of studies can be examined too. As described
in the next section, meta-analysis was developed specifically to answer
questions about psychotherapy outcome but has been utilized to serve
all of science. A major strength of the meta-analytic approach is that
it controls for outlier findings among individual studies that may run
counter to the larger body of literature.
Nonetheless meta-analysis is not without controversy, and individ-
ual meta-analyses as well as the technique itself have been criticized.
There are four basic problems that need to be addressed in a meta-anal-
ysis: (1) study heterogeneity or “comparing apples with oranges”; (2)
study quality, or “garbage in, garbage out”; (3) inclusion and exclusion
criteria, where small conceptual differences between meta-analyses can
result in vastly different answers; and (4) dissemination bias. The latter,
called the “file drawer problem,” is when studies with negative results
or results that counter the bias of the investigators are less likely to
EFFICACY OF PSYCHOTHERAPY 385
be published and appear in meta-analyses. Based on these critiques a
number of guidelines for conducting and reporting meta-analyses have
been developed (AMSTAR; Shea et al., 2009; MARS; APA, 2008; PRIS-
MA; Moher, Liberati, Tetzlaff, & Altman, 2009). Nevertheless, consum-
ers of meta-analytic findings, similar to consumers of findings from in-
dividual studies, need to be aware of how these methodological issues
raised have been addressed in interpreting the findings.
DOES PSYCHOTHERAPY wORK?
Controversy about the effectiveness of psychotherapy began in 1952
when the British experimental psychologist, Hans Eysenck, caused a
furor when he proclaimed that psychotherapy was no more beneficial
than the absence of treatment. In his report, Eysenck (1952) summa-
rized the results of 24 reports of psychoanalytic and eclectic psycho-
therapies with more than 7,000 neurotic clients treated in naturalistic
settings compared with two control groups. Eysenck found that the
more intensive the therapy, the worse the results. In fact, Eysenck’s
interpretation suggested that clients in psychoanalytic treatment had
significantly worse cure rates than clients who received no treatment.
It has been more than 60 years since Eysenck rocked the psycho-
therapy community with these claims. Despite the use of what is now
considered seriously flawed research methodology (e.g., inconsistent
methods, selection bias, inappropriate control groups) and a polemic
tone that some feel indicated a pre-existing bias, Eysenck’s article was
extremely important to the field and challenged therapists to pay more
systematic attention to the results of their efforts and has spurred a
great deal of empirical research. Thanks in large part to researchers’
response to Eysenck’s charge, we now know, generally speaking, that
psychotherapy does indeed help people get better (Smith, Glass, &
Miller, 1980; Wampold, 2001). Numerous studies and subsequent meta-
analyses have demonstrated that any number of specific psychothera-
peutic approaches, either alone, or, in some cases, in combination with
pharmacological approaches, are more effective than credible alterna-
tive psychological interventions containing nonspecific factors (e.g., the
provision of hope, support, empathy, or interventions provided by ex-
perts) serving as “psychological placebos” (Barlow, 1996).
Early on, there were a number of critiques of Eynseck’s review. The
most notable were by Christie (1956), Bergin (1971), Lambert (1976),
Luborsky, Singer, and Luborsky (1975), Rosensweig (1954), and Strupp
(1963). However, one critique in particular revolutionized not only the
field of psychotherapy and psychotherapy research but all of science.
386 LEvY ET AL.
In response to Eysenck’s use of a tally method for his comprehensive
review, Gene Glass (Smith & Glass, 1977) developed meta-analysis as a
method for generating a common metric that could be used aggregate
or combine findings across studies. As mentioned above, meta-analysis
is now used in every science, applied or basic, to summarize findings
across studies, and because of this capacity is considered to be able to
provide the highest level of evidence available to scientists and practi-
tioners (for a discussion from a medical perspective, see for example,
Rawlins, 2008, 2011).
In the late 1970s and early 1980s, Glass and colleagues (Smith &
Glass, 1977; Smith, Glass, & Miller, 1980) published a large review pa-
per and book of their initial meta-analysis in which they summarized
the findings of 375 psychotherapy outcome studies completed at that
time. Based on these findings, Glass and colleagues concluded that psy-
chotherapy did indeed convincingly lead to significant improvements
in treated patients: On average, the typical therapy patient is better off
than 75% of untreated individuals. Few reliable differences were found
between different types of psychotherapy. Since Glass and colleagues’
original meta-analysis there have been numerous meta-analytic re-
views of psychotherapy in general with mixed clients, psychotherapy
of specific psychotherapy orientations such as CBT (Butler, Chapman,
Forman, & Beck, 2006; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012)
or PDT (Barber et al., 2013; Driessen et al., 2010; Leichsenring & Rabung,
2008, 2011), psychotherapies for specific disorders such as depression
(Cuijpers, van Straten, van Oppen, & Andersson, 2008; Driessen et al.,
2010), anxiety disorders (Keefe, McCarthy, Dinger, Zilcha-Mano, & Bar-
ber, 2014), personality disorders (Leichsenring & Leibing, 2003), and
other disorders such as schizophrenia (Gottdiener & Haslam, 2003).
The overwhelming consensus across these meta-analyses is that a num-
ber of different psychotherapies are effective, and particularly so when
compared to no treatment wait-list controls or placebos. Consistent
with these findings, the American Psychological Association’s Division
12 Task Force on empirically supported psychotherapies now lists 13
separate psychotherapy treatments for depression, five treatments for
various anxiety disorders, and four treatments for borderline person-
ality disorder (APA, Division 12, 2013). Supporting the early findings
of Smith and Glass (1977), and despite the differences in the number
of studies conducted as a function of psychotherapy orientation, there
are few reliable differences between orientations across meta-analytic
studies. This finding in and of itself suggests that there are a number of
useful and effective psychotherapy treatments available to the practic-
ing clinician for treating patients.
EFFICACY OF PSYCHOTHERAPY 387
As contemporary researchers increasingly agree that psychotherapy
works, psychotherapy research is, nevertheless, at a critical period. A
confluence of pressures both inside (e.g., evidence-supported treatment
movement, practice guidelines) and outside the profession (e.g., man-
aged care, legislation, National Alliance for the Mentally Ill) make it
incumbent upon therapists to become better informed about the use-
fulness of psychotherapy and the evidence for it. There has been a shift
toward focusing research efforts on more precise questions, including
those such as: Given a patient’s diagnosis, which treatment is recom-
mended? What treatments have shown efficacy in empirical trials?
Does the therapy produce results beyond simply symptom change? Do
the changes achieved during the course of treatment endure with time?
How does length of treatment affect the nature of long-term outcome?
Which treatments that show efficacy in clinical trials have demonstrat-
ed similar effectiveness in community treatment settings?
In the following section we will examine the evidence for the use of
psychodynamic psychotherapy with a range of specific psychological
and psychiatric disorders. We will examine findings from (1) meta-ana-
lytic studies; (2) RCTs; (3) naturalistic studies, and (4) process-outcome
studies.
EFFECTIvENESS AND EFFICACY OF PSYCHOTHERAPY
FOR SPECIFIC DISORDERS
Overall, the effect sizes from meta-analytic studies suggest that psy-
chodynamic psychotherapy is more effective than placebo, as effective
as much-studied CBT, and possibly more effective than antidepres-
sants. We will review specific studies that will illustrate particularly im-
portant findings. These relate for example to good long-term outcomes,
to evidence for what has been termed a “sleeper effect” of continued
improvement after treatment termination, to positive effects especially
in the area of personality disorders and interpersonal difficulties, go-
ing beyond mere symptom reduction, and some evidence for possibly
specific mechanisms of change.
REvIEwING STUDIES ON MAjOR DIAGNOSTIC CATEGORIES
Personality Disorders
Personality Disorders are considered a major treatment challenge
in and of themselves, and they also complicate the treatment of other
388 LEvY ET AL.
disorders. For example, there are now a number of independent large-
scale outcome and longitudinal studies that show that comorbid per-
sonality disorders (PD), particularly borderline personality disorder
(BPD), not only affects treatment outcome of major depressive disorder
(MDD) adversely (Fournier et al., 2008; Shea, Widiger, & Klein, 1992),
but also lead to lower rates of remission, longer times to remission, and
increased relapse rates (Grilo et al., 2010; Gunderson et al., 2004; Links,
Heslegrave, Mitton, van Reekum, & Patrick, 1995; Newton-Howes et
al., 2006; Skodol et al., 2011; Zanarini, Frankenburg, Hennen, & Silk,
2006). Fournier and colleagues (2008) in a comparative study of CBT
with paroxetine found that treatment was less effective for those MDD
patients with a comorbid PD and that almost all MDD patients with a
comorbid PD relapsed upon discontinuation of medication. Although
the response rate for CBT was negatively affected by the presence of a
PD, in contrast to the medication condition, those that did respond to
CBT tended not to relapse. Grilo et al. (2010), in a six-year prospective
longitudinal study, found that a comorbid PD predicted longer time
to remission in MDD and faster time to relapse compared with MDD
patients without a PD. Skodol et al. (2011), in a nationally representa-
tive sample of over 5000 individuals, found that MDD patients with
comorbid BPD represented approximately half of the patients who did
not remit as of a three-year period. Surprisingly, there are now find-
ings from four impendent longitudinal studies (Gunderson et al., 2004;
Links et al., 1995; Skodol et al., 2011; Zanarinni et al., 2006) that have
found the negative effects of BPD on MDD seem to work in one direc-
tion. That is, MDD does not seem to have the same negative effect on
outcome in BPD. For instance, the rate of remission of BPD is not af-
fected by whether or not patients had co-occurring MDD, or whether
MDD responded to medication. For instance, Gunderson et al. (2004) in
a sample of 675 found that improvements in MDD were not followed
by improvements in BPD, whereas improvements in BPD were often
followed by improvements in MDD. Similar findings were reported
with regard to the relationship between PDs (especially BPD) with bi-
polar disorder (Bieling, Green, & Macqueen, 2007; Colom et al., 2000;
George, Miklowitz, Richards, Simoneau, & Taylor, 2003; Gunderson et
al., 2006; Kay, Altshuler, Ventura, & Mintz, 2002) and anxiety disorders
(Ansell et al., 2011). Thus, personality disorders, especially BPD, given
their prevalence, comorbidity, and consequences are a major health
concern that clinicians need to be prepared to address.
Before reviewing the research on specific models of therapy for spe-
cific personality disorders, we point to several meta-analyses of psy-
chotherapy for combined personality disorders that provide encourag-
ing findings (Budge et al., 2013; Leichsenring & Leibing, 2003; Perry,
EFFICACY OF PSYCHOTHERAPY 389
Banon, & Ianni, 1999). Perry and colleagues (1999) identified 15 studies,
including six RCTs, and found pre-post effect sizes ranging from 1.1 to
1.3. In a second meta-analysis, Leichsenring and Leibing (2003) exam-
ined the efficacy of both PDT (14 studies) and CBT (11 studies) in the
treatment of patients with personality disorders; 11 of the studies were
RCTs. The authors reported pre-treatment to post-treatment effect sizes
using the longest term follow-up data reported in the studies. For psy-
chodynamic psychotherapy (mean length of treatment was 37 weeks),
the mean follow-up period was 1.5 years after treatment end and the
pre-treatment to post-treatment effect size was 1.46, indicating that
psychodynamic treatment benefits endure over time. For CBT (mean
length of treatment was 16 weeks), the mean follow-up period was 13
weeks, and the pre-treatment to post-treatment effect size was 1.0. The
authors concluded that both PDT and CBT demonstrated effectiveness
for patients with personality disorders, but that current evidence for
long-term effectiveness is stronger for psychodynamic psychotherapy.
In the most recent and comprehensive meta-analysis on PDs, Budge
and colleagues (2013) analyzed 30 studies that compared an active psy-
chotherapeutic treatment with treatment as usual. They found that ac-
tive psychotherapeutic treatments were more efficient than treatment
as usual comparisons, with medium effect size (d = .40). In addition, the
effectiveness of PDT for individuals with personality disorders is sup-
ported by two more recent meta-analytic studies for short-term PDT
(Town, Abbass, & Hardy, 2011) and for the treatment of depression with
comorbid personality disorders (Abbass, Town, & Driessen, 2011).
To summarize, based on limited data, psychodynamic and CBT treat-
ments appear to be equally effective for personality disorders, yet lon-
ger term treatments might yield better outcomes, and psychodynamic
treatments may have longer lasting effects. However, findings from
these meta-analyses of personality disorders are difficult to interpret
due to the mixing samples that can vary quite a bit in terms of severity.
Thus research on specific personality disorders is informative.
Borderline Personality Disorder (BPD)
BPD patients have traditionally taken up high levels of treatment re-
sources (Bender, Dolan, & Skodol, 2001) and have been considered a
difficult population to treat effectively. Four psychodynamic treatments
for borderline personality have empirical support: Russell Meares’s In-
terpersonal-Self Psychological approach also known as the Conversa-
tional Approach, Bateman and Fonagy’s Mentalization Based Therapy
390 LEvY ET AL.
(MBT; Bateman & Fonagy, 2004), Kernberg et al.’s Transference Focused
Psychotherapy (TFP; Clarkin, Yeomans, & Kernberg, 2006), and Robert
Gregory’s Deconstructive Dynamic Psychotherapy (DDP; Gregory &
Remen, 2008). The latter three have been shown to be efficacious in
RCTs.
Interpersonal-Self Psychological Approach. Meares developed an inter-
personal self-psychological approach for the treatment of BPD guided
by the conversational model of Hobson (1985), the main aim of which
is to foster the emergence of reflective consciousness that William
James called self-consciousness (James, 1890). A basic tenet of this ap-
proach is that self-consciousness is achieved through a particular form
of conversation and reflects a deeper sense of relatedness. A pre-post
study that evaluated the effects of this approach for patients with BPD
found that patients at the end of treatment showed an increase in time
employed and decreases in number of medical visits, number of self-
harm episodes, and number and length of hospitalizations (Stevenson
& Meares, 1992). Although the inferences that can be drawn from this
study are limited by the lack of a control group, these findings sup-
ported the further development and study of psychodynamic treat-
ments for BPD. In a later quasi-experimental study (Meares, Stevenson,
& Comerford, 1999), researchers compared BPD patients treated twice
weekly for one year with those in a treatment-as-usual (TAU) waitlist
control group (all waitlisted patients received their usual treatments,
which consisted of supportive psychotherapy, crisis intervention only,
cognitive therapy, and pharmacotherapy). Thirty percent of patients
with interpersonal-psychodynamic psychotherapy no longer met cri-
teria for a DSM-III (American Psychiatric Association, 1980) BPD diag-
nosis at the end of the treatment year, whereas all of the TAU patients
still met criteria for the diagnosis. These results demonstrated that psy-
chotherapy based on psychodynamic principles is generally beneficial
to patients with BPD in a naturalistic setting, having strong ecological
validity in a real world setting. A five-year follow-up found the im-
provements were maintained (Stevenson, Meares, & D’Angelo, 2005).
A second quasi-experimental study (Korner, Gerull, Meares, & Steven-
son, 2006) replicated these findings.
Mentalization Based Therapy. Bateman and Fonagy (2004, 2006) devel-
oped Mentalization Based Therapy (MBT) that integrates philosophy
(theory of mind) and elements of psychoanalytic traditions (ego psy-
chology, Kleinian theory, and attachment theory). They posit that the
mechanism of change in all effective treatments for BPD involves the
capacity for mentalization—the capacity to think about mental states in
oneself and in others in terms of wishes, desires, and intentions. Men-
EFFICACY OF PSYCHOTHERAPY 391
talizing involves both (1) implicit or unconscious mental processes that
are activated along with the attachment system in interpersonal situ-
ations and (2) coherent integrated representations of mental states of
self and others that influence thinking, emotional states, and behavior.
The concept of mentalization has been operationalized in the Reflective
Function (RF) scale (Fonagy, Steele, Steele, & Holder, 1997).
In an RCT (Bateman & Fonagy, 1999), the effectiveness of 18 months
of an MBT day hospitalization program was compared with routine
general psychiatric care for patients with BPD. Patients randomly as-
signed to the day hospital program showed statistically significant
improvement in depressive symptoms and better social and interper-
sonal functioning, and significant decreases in suicidal and parasui-
cidal behavior and number of inpatient days. Patients were reassessed
every three months for up to 18 months post-discharge (Bateman &
Fonagy, 2001). Short-term follow-up results indicated that patients who
completed the MBT not only maintained their substantial gains, but
also showed continued steady and significant improvement on most
measures, suggesting that BPD patients can continue to demonstrate
gains in functioning long after treatment has ended. At 18-month post-
discharge follow-up, 59.1% of patients treated with MBT were below
the BPD diagnostic threshold, compared to only 12.5% of those treated
in routine general psychiatric care. In a second follow-up, eight years
post randomization and five years post the end of treatment, even more
impressive findings were obtained: those treated with MBT showed not
only statistical superiority in reduced suicidality, service utilization,
medication use, and increases in global and vocational functioning,
but an impressive level of clinical change (only 13% met criteria for
BPD compared to 87% of those in the TAU group; Bateman & Fonagy,
2008). A recent RCT found MBT to be as effective as supportive psycho-
therapy in most of the outcome measures, but slightly more effective in
improvement of global functioning (Jørgensen et al., 2013).
In summary, findings on the long-term significance of MBT are par-
ticularly important given the entrenched and chronic nature of BPD.
Follow-up studies of CBT treatments for BPD have typically examined
relatively short time frames (between 6 and 18 months), leaving the
long-term efficacy of these treatments unclear. Additionally, outcomes
for these studies have generally been mixed.
Transference Focused Psychotherapy (TFP). TFP is a modification of
psychodynamic therapy based on object relations theory to address the
needs of patients with BPD. TFP aims to reduce the patient’s use of
primitive defenses that deny the patient access to important parts of
his emotional experience and to increase the patient’s coherent sense of
392 LEvY ET AL.
self as a means to reduce suicidality and self-injurious behaviors, and
to facilitate better behavioral control, increased affect regulation, more
gratifying relationships, and the ability to purse life goals (Clarkin, Yeo-
mans, & Kernberg, 2006; Kernberg, Yeomans, Clarkin, & Levy, 2008).
Using clarifications, confrontations, and interpretations, the therapist helps
the patient integrate cognitions and affects that were previously split
off and disorganized. The tactful interpretation of the dominant themes
that the patient experiences in the here and now of the transference shed
light on the reasons that internal representations of self and other re-
main fragmented and thus facilitate the development of a coherent
sense of self and others.
There is accumulating evidence for the effectiveness and efficacy
of TFP. An initial study (Clarkin et al., 2001) with a pre-post design
showed that patients with BPD who were treated with TFP had marked
reductions in the severity of parasuicidal behaviors, fewer emergency
room visits, hospitalizations, days hospitalized, and reliable increases
in global functioning. The effect sizes were large and equal to those
demonstrated by other BPD treatments (Bateman & Fonagy, 1999; Line-
han, Armstrong, Suarez, Allmon, & Heard, 1991). The one-year drop-
out rate was 19.1%, and no patient committed suicide. These results
compared well with other treatments for BPD.
A second quasi-experimental study (Levy, Clarkin, Foelsch, & Kern-
berg, 2007) provided further support for the effectiveness of TFP in
treating BPD. Twenty-six women diagnosed with BPD and treated
with TFP were compared to 17 patients in a TAU group. There were no
significant pre-treatment differences between the treatment group and
the comparison group in terms of demographic or diagnostic variables,
severity of BPD symptomatology, baseline emergency room visits,
hospitalizations, days hospitalized, or global functioning scores. The
one-year drop-out rate was 19%. Patients treated with TFP, compared
to those treated with TAU, showed significant decreases in suicide at-
tempts, hospitalizations, and number of days hospitalized, as well as
reliable increases in global functioning. All of the within-subjects and
between-subject effect sizes for the TFP-treated participants indicated
favorable change. The within-subject effect sizes ranged from 0.73 to
3.06 for the TFP-treated participants, with an average effect size of
1.19—well above what is considered a “large” effect (Cohen, 1988).
In an RCT (Clarkin et al., 2007; Levy et al., 2006), 90 clinically referred
patients were randomized to one of the three treatments: TFP, DBT, and
a psychodynamic supportive psychotherapy (SPT; Appelbaum, 2005).
Results of individual growth-curve analysis indicated that both the
TFP and DBT-treated groups, but not the SPT group, showed signifi-
EFFICACY OF PSYCHOTHERAPY 393
cant decrease in suicidality. Both TFP and supportive treatment were
associated with improvement in anger and with improvement in facets
of impulsivity. Only the TFP-treated group demonstrated significant
improvements in irritability, verbal assault, and direct assault.
In an earlier report on this sample, Levy and colleagues (Levy et
al., 2006) examined changes in attachment organization and reflective
function as putative mechanisms of change, using the Adult Attach-
ment Interview (AAI; George, Kaplan, & Main, 1985) and the Reflective
Function coding scale (RF; Fonagy, Steele, Steele, & Target, 1997). After
12 months of treatment there was a significant increase in the number
of patients classified as secure with respect to attachment state of mind
for TFP, but not the other two treatments. Significant changes in nar-
rative coherence and RF were found as a function of treatment, with
TFP showing increases in both constructs during the course of treat-
ment. These findings are important as they show that TFP is not only
an efficacious treatment for BPD, but works in a theoretically predicted
way and thus has implications for conceptualizing the mechanism by
which patients with BPD may change. The fact that patients in TFP
did better on these putative mechanisms (e.g., reflective function) than
those in DBT and SPT is initial evidence that this form of psychody-
namic therapy is associated not only with symptom change but also
with underlying psychological processes that mediate the patient’s ad-
justment to the world. This is significant in the context of the literature
showing that many treatments do not show specific effects on specific,
theory-driven mechanisms (Ablon & Jones, 1998; Ablon, Levy, & Kat-
zenstein, 2006; Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; De-
Rubeis et al., 1990; DeRubeis & Feeley, 1990; Ilardi & Craighead, 1994;
Jones & Pulos, 1993; Shaw et al., 1999; Trepka, Rees, Shapiro, Hardy, &
Barkham, 2004).
TFP was also examined as a control condition in a study in Amster-
dam by Arntz and colleagues (Giesen-Bloo et al., 2006). The authors
compared TFP with Schema Focused Therapy (SFT; Young, 1994), an in-
tegrative approach based on cognitive-behavioral or skills-based tech-
niques along with object relations and gestalt approaches. Their study
is unique in examining two active treatments over three years, however
it lacked a control (Grenyer, 2007). While patients benefited from both
treatments, SFT appeared more efficacious. However, a number of seri-
ous limitations including failure in the randomization process (Levy,
Meehan, & Yeomans, 2012) and non-adherent therapists (Yeomans,
2006) argue against this conclusion. Additionally, a later independent
study (Doering et al., 2010) also found TFP to be efficacious, and a re-
cent meta-analysis of treatments for BPD failed to find any differences
in treatment effects between specific treatments (Levy et al., 2012).
394 LEvY ET AL.
Mixed and Other Personality Disorders
Other studies have examined psychodynamic psychotherapy for
personality disorders (Abbass, Sheldon, Gyra, & Kalpin, 2006; Win-
ston, Laiken, Pollack, Samstag, McCullough, & Muran, 1994; Winston,
Pollack, McCullough, Flegenheimer, Kestenbaum, & Trujullo, 1991).
Winston and colleagues compared a short-term psychodynamic psy-
chotherapy based on the work of Malan (1976) and Davanloo (1992)
and a short-term psychodynamic psychotherapy called Brief Adaptive
Psychotherapy (BAP) with a waitlist control in a group of patients pre-
dominately diagnosed with cluster C personality disorders. Both STPP
treatments address defensive behavior and elicit affect in interpersonal
contexts, although the BAP treatment is less confrontational. The au-
thors found that both treatment groups showed significant change on
the global severity index of the SCL-90 (approximately 1 standard devi-
ation) and some changes on the social adjustment scale. At 18 months,
post-treatment follow-up indicated the maintenance of treatment gains
(Winston et al., 1994). Abbass et al. (2006) examined STPP for outpa-
tients with a range of personality disorders. The authors found signifi-
cant improvement in interpersonal problems, significantly more hours
worked, and better employment outcomes relative to controls.
In another study using an RCT-design to examine outpatients with
cluster C personality disorders (avoidant, dependent, obsessive-com-
pulsive; Svartberg, Stiles, & Seltzer, 2004), the authors examined a 40-
week STPP compared with cognitive therapy (CT) and found no sta-
tistically significant difference between the short-term psychotherapy
group and CT groups on any measure for any time period. At two-year
follow-up, 54% of the short-term dynamic psychotherapy patients and
42% of the CT patients had recovered symptomatically.
Depression
Although the data base is not as large for psychodynamic treatments
of depression as it is for CBT, there is enough data to suggest that PDT
is equally effective, and thus should be available to patients, and that
further research is warranted on psychodynamic approaches. This con-
clusion is based on three sets of findings reviewed below: (1) meta-ana-
lytic studies; (2) RCTs; and (3) process-outcome studies.
Before turning to studies on depression, it is important to call atten-
tion to the emerging literature indicating a high rate of treatment failure
EFFICACY OF PSYCHOTHERAPY 395
or treatment resistance in depressed patients, and a growing interest in
management of what is commonly referred to as “treatment resistant
depression.” Treatment resistance is of particular relevance to this re-
view, as one of the reasons for resistance seems to be comorbidity. In the
large STAR*D study of depression, 78% of the sample had comorbidity
or other problems like suicidality that would have excluded subjects
from RCTs, but that made them similar to the majority of patients that
clinicians see. STAR*D found that the comorbid group was more intol-
erant of antidepressant medications, had lower rates of treatment re-
sponse (39% versus 52%), and lower rates of remission from depressive
symptoms (25% versus 34%) when compared with patients who did
not have comorbidity (Wisniewski et al., 2009). There is also evidence
that personality disorders in particular adversely affect the outcome of
major depressive disorders, cause persistent functional impairment, ex-
tensive treatment utilization, and are associated with a significant sui-
cide risk (Bender et al., 2006; Skodol et al., 2005). Personality disorders,
especially BPD “robustly predicted the persistence” of major depres-
sive disorder (Skodol et al, 2011), leading Skodol and his colleagues
to suggest that assessment and treatment of personality disorders is
essential in patients with major depressive disorder. Given the appar-
ent association of comorbidity, especially personality disorder comor-
bidity, with treatment resistance in depression (and other disorders),
research into the treatment of complex comorbid patients is indicated.
Meta-Analytic Studies on Therapy for Depression. The psychotherapy
treatment of depression is probably the most studied of any psycho-
logical disorder. In the last three decades alone, there have been 40 me-
ta-analytic reviews of the outcomes for patients with depression alone
(Cuijpers & Dekker, 2005; Lambert, 2013). A number of meta-analyses
have focused specifically on the psychodynamic treatment of depres-
sive disorders (Crits-Christoph, 1992). There are several meta-analytic
studies that examine the efficacy of psychodynamic psychotherapy
as compared with other active treatments, mostly CBT (Churchill,
Hunot, Corney, Knapp, McGuire, Tylee et al., 2002; Crits-Christoph,
1992; Driessen et al., 2010; Gloaguen, Cottraux, Cucheret, & Blackburn,
1998; Leichsenring, 2001; Svartberg & Stiles, 1991). Each of these meta-
analyses suggests good evidence for the efficacy of psychodynamic
psychotherapy and CBT (Crits-Christoph, 1992; Leichenring, 2001). A
number of these studies compared effect sizes in PDT with that of CBT
(Churchill et al., 2002; Gloaguen et al., 1998; Svartberg & Stiles, 1991). In
the Churchill et al. review, the authors found no significant differences
between groups post-treatment with regard to symptoms, symptom re-
duction, or dropout. Further, there were no differences between groups
396 LEvY ET AL.
at 3 months and 1-year follow-up. For the Gloaguen and colleague’s
meta-analysis, Wampold and colleagues (Wampold, Minami, Baskin,
& Callen Tierney, 2002) showed that there were no demonstrable dif-
ferences between PDT and CBT in studies in which CBT was compared
with bona-fide PDT (i.e., PDT defined as a clearly articulated model
of treatment). Leichsenring (2001) found no significant differences be-
tween CBT and PDT modalities in terms of depressive symptoms, gen-
eral psychiatric symptoms, or social functioning. The most recent meta-
analysis by Driessen et al. (2010) found short-term psychodynamic psy-
chotherapy (STPP) to be a viable option for the treatment of depression.
STPP was more effective than nonspecific TAU, and during follow-up
as effective as other specific psychotherapeutic treatments, mostly CBT.
Effect sizes for psychodynamic psychotherapy are quite large (be-
tween 0.90 and 2.80) with the average depressed patient treated in psy-
chodynamic psychotherapy better off than 82% to 100% of depressed
patients before therapy. As a point of comparison, the effect sizes for
antidepressant medications range between .24 for citalopram (Celexa)
and .31 for escitalopram (Lexapro; Turner, Matthews, Linardatos, Tell,
& Rosenthal, 2008), and effect sizes for medications decrease when an-
tidepressants are compared to active placebos (e.g., non-inert placebo
that mimics the side effects of an antidepressant drug but do not have
antidepressant components).
Randomized Controlled Trials on Therapy for Depression. Initially, brief
dynamic therapy was used as a comparison from which to assess the
validity of other treatments (Hersen, Himmelhoch, Thase, & Bellack,
1984). In these studies, PDT was not a bona fide treatment, meaning it
was not a clearly defined therapy but rather a “grab bag” term as little
attention was paid to a clearly articulated model of treatment, the ap-
propriateness of the therapists, or the fidelity of the treatment. More re-
cent studies have paid better attention to these issues and tend to show
that psychodynamic treatment is as effective as other modalities (Bar-
ber, Barrett, Gallop, Rynn, & Rickels, 2012a; Barkham, Shapiro, Hardy,
& Rees, 1999; Cooper, Murray, Wilson, & Romaniuk, 2003; Driessen et
al., 2013; Gallagher-Thompson & Steffen, 1994; Shapiro et al., 1994; Sha-
piro, Rees, Barkham, & Hardy, 1995). For example, Gallagher-Thomp-
son and Steffen (1994) found in an RCT that 20 sessions of brief psy-
chodynamic psychotherapy were as effective as 20 sessions of CBT in
reducing depression in caregivers of elderly family members. Shapiro
et al. (1994, 1995) randomized patients to 8 or 16 weeks of psychody-
namic-interpersonal psychotherapy or CBT. They found that both treat-
ments were equally effective for the 8-week and 16-week conditions,
EFFICACY OF PSYCHOTHERAPY 397
and that there were no group differences at one-year follow-up. In both
therapy conditions, severe depressions responded better to 16 weeks of
intervention, speaking to the length of treatment issue that we will dis-
cuss later in the article. Thus, similar effect sizes were found when PDT
was compared with CBT and these effects were comparable to those re-
ported in other studies of CBT and IPT. Two recent RCTs add to the evi-
dence. In a randomized-controlled study in a sample of patients with
low socioeconomic status, high psychiatric comorbidity, and a long ill-
ness duration, STPP was as effective as psychotropic medication with
SSRI/SNRIs (Barber et al., 2012). In the largest RCT for depression to
date, 341 patients were randomized to either 16 sessions of manualized
STPP or 16 sessions of manualized CBT accompanied with optional an-
tidepressant medication for severe cases. Results indicated that both
treatments are equally effective in symptom reduction (Driessen et al.,
2013). What is particularly important about this study is that with the
large sample size, it was sufficiently powered to test for equivalence on
a number of measures, which was found. This lead Thase (2013) in his
editorial in the American Journal of Psychiatry to declare that “. . . psy-
chodynamic psychotherapy is indeed an effective treatment option for
outpatients with major depressive disorder” (p. 954).
Process-Outcome Studies. A different approach to studying psycho-
therapy outcome focuses on the relationship between specific aspects
of therapy process—the techniques that are observed in the course of
the session—and treatment outcome. There are a number of process
studies that suggest the value of a psychodynamic approach for depres-
sion. Jones and Pulus (1993) found that although patients in both CBT
and PDT improved, improvement in both therapies was dependent
on the use of psychodynamic techniques embedded in the sessions in
each treatment. Indirect evidence for the importance of psychodynamic
process also comes from the findings of Castonguay, Goldfried, Wiser,
Raue, and Hayes (1996). In examining mechanisms of change in CBT
for depression, they found that focusing on distorted cognitions was
inversely related to successful treatment outcome. However, a focus on
feelings about the self, while elaborating and integrating emotional ex-
perience to develop an in-depth self-understanding, predicted positive
treatment outcome. These findings suggest that cognitive behavioral
therapists use psychodynamic strategies at times, and that these are as-
sociated with positive treatment outcome for patients of both psycho-
dynamic and cognitive-behavioral therapists.
398 LEvY ET AL.
Anxiety Disorders
The effectiveness of CBT for the treatment of anxiety disorders is
well established (Hofmann & Smits, 2008). In fact, during the 1980s and
1990s there were many RCTs examining CBT for a range of anxiety dis-
orders. By the later 1990s and early 2000s the literature in support of the
effectiveness of CBT was large enough to raise doubts about the value
or ethics of non-exposure based/CBT methods for treating a range of
anxiety disorders (Eagle, 2005). On the other hand, the outcome for
CBT was far from complete. Many patients relapsed and sought out
continued psychotherapy (Westen & Morrisson, 2001). Additionally,
the notion of CBT as a superior treatment was for the most part not
based on direct comparisons with bona fide treatments (e.g., PDT) but
rather comparisons to placebos and waitlist controls. Despite mounting
pressure from the academic community and insurance companies to
limit treatment for anxiety exclusively to CBT treatments, some clinical
researchers persisted with humanistic/existential and psychodynamic
approaches, resulting in several RCTs of PDT in the treatment of anxiety
disorders (Alström et al., 1984a, 1984b; Beutel et al., 2013; Bögels, Wijts,
Oort, & Sallaerts, 2014; Bressi, Porcellana, Marinaccio, Nocito, & Magri,
2010; Brom, Kleber, & Defares, 1989; Crits-Christoph, Wilson, & Hollon,
2005; Durham et al., 1994; Leichsenring et al., 2013; Milrod et al., 2007;
Pierloot & Vinck, 1978; Wiborg & Dahl, 1996). Overall, the evidence is
positive for the effectiveness of PDT for a range of anxiety disorders as
indicated from findings from a recent meta-analysis including 14 RCTs
with 1073 patients (Keefe et al., 2014). The within-group effect size for
PDT was large (g = 1.06). Psychodynamic treatment was always supe-
rior to waitlist control or minimal care interventions in five RCTs. PDT
was equally effective when compared with other active treatments,
with all but three comparison treatments being CBT or BT spectrum
treatments. For example, two smaller RCTs compared psychodynamic
psychotherapy with CBT (Bögels et al., 2014; Durham et al., 1994); one
found the treatments equally effective (Bögels et al., 2014) and the other
found that PDT provided significant improvement but to a lesser de-
gree than CBT (Durham et al., 1994). However, in the latter study, in
contrast to the CBT treatment, PDT was not manualized, there was no
specific training of therapists, and there were neither adherence checks
nor treatment fidelity monitoring for the dynamic therapists.
A particularly important RCT was conducted by Milrod and col-
leagues (2007) who manualized a psychodynamic treatment for panic
EFFICACY OF PSYCHOTHERAPY 399
based on theory and case reports that focused on symptom reduction
through exploring unconscious determinants, such as unacknowledged
anger and conflicts regarding autonomy and dependence. Panic Fo-
cused Psychodynamic Psychotherapy (PFPP) is aimed at helping pa-
tients understand the underlying emotional meaning of their panic al-
lowing patients to acknowledge previously unacceptable feelings and
ideas that have led to panic. This contrasts with CBT, which relies on ex-
posure to panic triggers (i.e., bodily sensations such as breathlessness,
tightness in the chest, heart palpitations), and a highly structured set
of exercises aimed at easing attacks. In an RCT, Milrod and colleagues
compared PFPP over 12 weeks to Applied Relaxation Therapy (ART),
a standard and structured relaxation-focused approach that has often
been used in trials aimed at assessing the effectiveness of other treat-
ment approaches. Results showed not only efficacy for PDT but found
similar effect sizes to those seen in studies of CBT, and a lower drop-
out rate than typical in CBT. The 26 patients in the PFPP group had a
greater reduction in their symptoms compared to the 23 patients in the
ART group, with 73% of PFPP patients meeting criteria for “response,”
compared to just 39% of those in the ART cohort. Even more impor-
tant, moderator analyses (Milrod, Leon, Barber et al., 2007) revealed
that PFPP was particularly useful for panic patients who had a comor-
bid personality disorder. This is important given that a host of reviews
suggest that anxiety patients with comorbid personality disorders do
not benefit as much in standard CBT as those without the comorbid-
ity (Brooks, Baltazar, & Munjack, 1989; Massion, Dyck, Shea, Phillops,
Warshaw, & Keller, 2002; Noyes et al., 1990; Pollack, Otto, Rosenbaum,
& Sacks, 1992; Reich & Green, 1991; Yonkers, Dyck, Warshaw, & Keller,
2000; see review by Mennin & Heimberg, 2000). If replicated, these re-
sults would make Panic Focused Psychodynamic Psychotherapy the
treatment of choice for patients with panic disorder and personality
disorder.
A second RCT for panic disorder (Beutel et al., 2013) compared PFPP
with CBT and found no differences in remission rates or difference in
symptom change scores between PFPP and CBT when taking patient
baseline level of emotional processing into account. Taken together,
PFPP has proved its effectiveness in two independent RCTs, both
against a fair TAU group as well as against a strong CBT comparator.
For generalized anxiety disorder, Leichsenring and colleagues (2009;
Salzer, Winkelbach, Leweke, Leibing, & Leichsenring, 2011) found no
differences between STPP and CBT with regard to expert-rated symp-
tom reduction in a small RCT. Regarding social phobia, a large multi-
center RCT comparing STPP with CBT found both treatments to be
equally effective with regard to response rates and more effective than
400 LEvY ET AL.
a waitlist control group (Leichsenring et al., 2013). In the short term,
the CBT group had higher remission rates, but these differences dis-
appeared in the two-year follow-up assessment (Leichsenring, 2013).
Finally, one RCT found that psychodynamic treatment combined with
pharmacotherapy was more effective in preventing relapse for panic
disorder than pharmacotherapy alone (Bressi et al., 2010).
Somatic Symptoms
There are a growing number of studies showing evidence for the ef-
fectiveness of PDT in treating psychosomatic symptoms. In one RCT, 16
sessions of STPP added to the medical treatment as usual (TAU) were
more effective than the medical treatment alone in patients with func-
tional dyspepsia (Faramazi et al., 2013). Another RCT on women with
breast cancer and comorbid depression found psychodynamic group
psychotherapy to be more effective with regard to depression, quality
of life, and other variables than TAU (Beutel et al., 2013). While some
studies failed to find a superiority of PDT over specialized enhanced
primary care (see for example Scheidt et al., 2013), two recent meta-
analyses on the impact of STPP on somatic symptoms (Abbass, Kisely,
& Kroenke, 2009) and general psychotherapeutic approaches on severe
somatoform disorder (Koelen et al., 2014) present compelling evidence
on the effectiveness of psychotherapeutic interventions in this difficult
to treat patient group. Koelen and colleagues found a slight superiority
of psychodynamic over CBT approaches on the improvement of patient
functioning, though not on symptom change. Especially relevant for
GPs are findings that additional, psychodynamically informed group
therapy reduced symptom distress and GP visits in an RCT with diffi-
cult to treat patients with medically unexplained symptoms (Schaefert
et al., 2013).
Eating Disorders
Several randomized control trials have examined psychodynamic
treatment for eating disorders (Bachar, Latzer, Kreitler, & Berry, 1999;
Crisp et al., 1991; Dare, Eisler, Russell, Treasure, & Dodge, 2001; Fair-
burn, Kirk, O’Connor, & Cooper, 1986; Garner et al., 1993; Gowers,
Norton, Halek, & Crisp, 1994; Hall & Crisp, 1987; Russell, Szmukler,
Dare, & Eisler, 1987). The general finding was that for anorexia nervosa,
psychodynamic treatment is as effective as other treatments, including
EFFICACY OF PSYCHOTHERAPY 401
behavioral and strategic family therapy (Crisp et al., 1991; Dare et al.,
2001; Gowers et al., 1994; Hall & Crisp, 1987; Russell et al., 1987). Gow-
ers et al. found significant improvements in weight and body mass in-
dex as compared to a TAU control condition. Dare and colleagues found
that both psychodynamic psychotherapy and family therapy were sig-
nificantly superior to routine treatment in terms of weight gain. With
regard to bulimia nervosa, Fairburn et al. (1986) and Garner et al. (1993)
found that psychodynamic and CBT treatments resulted in comparable
improvements in bulimic episodes and self-induced vomiting although
CBT was superior on other measures of general psychopathology. At
follow-up both were equally effective and superior to pure behavior
therapy (Fairburn et al., 1995) suggesting that both CBT and psycho-
dynamic treatment are preferred choices over behavior therapy. On the
other hand, a very recent study on the treatment of bulimia nervosa
compared a non-directive psychodynamic therapy with a shorter but
highly specific CBT intervention. Both led to significant symptom im-
provement, but the CBT intervention was more effective (Poulsen et al.,
2014). More research is needed on the effectiveness of PDT in bulimia.
In the Anorexia Nervosa Treatment of Outpatients (ANTOP; Zipfel
et al., 2014) trial, the largest study to date on the treatment of anorexia
nervosa, 242 women were randomized to either 40 hours of focal STPP,
enhanced CBT, or optimized treatment as usual by experienced com-
munity therapists. All three treatments were effective with regard to
weight gain. However, there were more dropouts in the treatment by
community TAU experts than in both manualized intervention groups.
While STPP was equally effective as CBT at the end point of treatment,
only psychodynamic therapy was more effective than TAU by commu-
nity experts at 12-months follow-up.
Marital Therapy
In a controlled outcome study, Snyder, Wills, and Grady-Fletcher
(1991) followed up 59 couples four years after receiving either behav-
ioral or insight-oriented martial therapy. There were no group differ-
ences between the two treatment conditions at either termination or
six-month follow-up. However, at four-year follow-up couples who re-
ceived the insight-oriented therapy were more likely to be happily mar-
ried (79% vs. 50%), whereas the couples who received the behavioral
therapy were more likely to be divorced (38% vs. 3%).
402 LEvY ET AL.
Schizophrenia
There is clear evidence for the limited efficacy of CBT in the treat-
ment of schizophrenia. In this context, a recent review conducted by
the rigorous standards of the Cochrane Collaboration found other
“active” psychological interventions equally effective (Jones, Hacker,
Cormac, Meaden, & Irving, 2012). Furthermore, results from new tri-
als on alternate approaches yield promising results, allowing patients
to have a wider variety of treatment options. For example, in a con-
trolled study, a manual-based supportive psychodynamic psycho-
therapy showed large effects in general as well as in specific treatment
domains in patients with a first episode of psychosis after two years of
treatment (Rosenbaum et al., 2012). In addition, it was more effective
in the improvement of overall symptoms and functioning than TAU,
with small to medium effects. These results are in line with an earlier
study by Rosenbaum and colleagues (2006), where one weekly session
of supportive psychodynamic psychotherapy was more effective than
TAU, and as effective as a time-intensive, multimodal treatment after
one year.
SUMMARY OF EMPIRICAL FINDINGS wITH
PSYCHODYNAMIC PSYCHOTHERAPY
In summary, psychodynamic psychotherapy appears to be as effec-
tive as other treatments: effect sizes from meta-analyses suggest that it
is equally, and sometimes even more effective than other psychothera-
py, as effective as CBT, and often more effective than antidepressants.
Although controversial, there are also a number of reasons to suggest
the value of longer-term psychodynamic treatments for depression and
anxiety. First, the long-term outcome and relapse rates from studies
of depression strongly suggest the need for more intensive treatment.
Despite reasonable short-term efficacy, the long-term efficacy of short-
term versions of CBT, IPT, and PDT, as well as for medication treatment
is poor. Second, there is an established literature showing that short-
term treatments tend to ameliorate demoralization and symptoms but
do not lead to more established rehabilitative changes in personality
and functioning (Howard, Lueger, Maling, & Martinovich, 1993). These
two sets of findings taken together suggest the need for longer and
more intensive interventions. Third, there are findings from meta-anal-
EFFICACY OF PSYCHOTHERAPY 403
yses, particularly of within-group effects that have found large effects
for longer-term treatments (de Maat, de Jonghe, Schoevers, & Dekker,
2009; Leichsenring & Rabung, 2008, 2011). Finally, there are a number
of quasi-experimental as well as experimental studies (i.e., RCTs) that
have found superiority for longer-term PDT as compared to short-term
(Knekt et al., 2008; Knekt, Lindfors, Laaksonen et al., 2011; Knekt, Lind-
fors, Renlund et al., 2011). Across individual studies, both experimental
studies such as RCTs and more naturalistic studies, as well as multiple
meta-analyses, and across a number of disorders, the findings are quite
consistent in suggesting the value of psychodynamic psychotherapy
in reducing the burden of mental illness. Empirical support for the
usefulness of PDT exists for the treatment of depression, anxiety disor-
ders, eating disorders, personality disorders, substance abuse, somatic
symptoms, and marital discord. Emerging evidence also points toward
the effectiveness of PDT for schizophrenia.
COMMON MISCONCEPTIONS ABOUT PSYCHOTHERAPY
AND MEDICATION
There are a variety of commonly held misconceptions among clini-
cians as well as patients with regard to psychotherapy outcome as com-
pared with medication management. Medications are often prescribed
as a first-line intervention for the treatment of depressive and anxiety
disorders (Otto, Smits, & Resee, 2005). However, the evidence that
these disorders often respond more reliably to psychotherapeutic in-
tervention (often with fewer untoward effects) is frequently neglected.
Results of both individual RCTs and meta-analytic reviews suggest
that for a range of disorders such as borderline personality disorder, de-
pressive disorders, and many anxiety disorders, psychotherapy should
be the first line and/or primary treatment (DeRubeis, Siegle, & Hollon,
2008; Fournier et al., 2010; Hollon et al., 2005; Wexler & Cicchetti, 1992).
For borderline personality disorders, medications can be an important
augmentation, by taking the edge off certain symptoms, although their
use can also result in iatrogenic problems (Frankenburg & Zanarini,
2006, 2011). For depression, medications may be indicated when de-
pression is severe and includes neurovegative signs or there is a wors-
ening clinical picture. Some have noted that in these cases medications
can help the patient be more available for psychotherapy (Roose & Jo-
hannet, 1998)—while this might be true, especially in the case of neu-
rovegative signs, such an understanding is very different from medica-
tions serving as the only treatment provided, as is increasingly the case.
404 LEvY ET AL.
Similar findings exist for anxiety disorders (Otto, McHugh, & Kantak,
2010) where the combination of medications and psychotherapy do not
yield greater improvements relative to either treatment alone. While
medications might be useful for brief periods to help control anxiety,
it is important to note that their use often undermines the effective-
ness of psychotherapy, particularly CBT and BT approaches that rely
on exposure and new learning or extinction (Hart, Panayi, Harris, &
Westbrook, 2014; Otto, McHugh, & Kantak, 2010).
With regard to the treatment of depression, Wexler and Cicchetti
(1992) published a meta-analysis examining treatment success rates,
treatment failure rates, and treatment dropout rates. Findings indicat-
ed that although psychotherapy and medications were both effective,
psychotherapy produced a higher success rate (47%) than medication
(29%) and that the combination of the two did not provide any addi-
tional benefit over that of psychotherapy alone (47%); however, adding
psychotherapy to medication did provide some benefit over medication
alone (47% for the combined psychotherapy and medication). More-
over, the use of medication, either alone or in combination with psycho-
therapy resulted in increased risk of dropout from treatment and other
negative side effects. Thus they concluded with the very reasonable
recommendation that the first-line treatment for depression should be
a course of individual psychotherapy rather than exposing patients to
unnecessary costs and side effects associated with combined treatment
or medication alone. Only if there is no improvement in four months
of treatment, or if there is a worsening of symptoms, should medica-
tion be introduced. Shortly after this publication, a letter to the editor
chastised Wexler and Cicchetti’s conclusion that psychotherapy be con-
sidered the initial treatment of choice by noting that it was difficult to
imagine insurance companies adhering to their recommendation. Wex-
ler and Cicchetti responded that if that was true it would be a shame
because they would be ignoring the data. Since that meta-analysis,
there have been many additional studies and meta-analyses examin-
ing psychotherapy, medication, and their combined effects in the treat-
ment for depression (Huhn et al., 2014). The general effect sizes from
meta-analyses for psychotherapy tend to be considerably larger than
the effect sizes found in meta-analyses examining medication (effect
size estimates = 0.31 for medications vs. effect size estimates ranging
from .85 to 1.48 for psychotherapy; see Shedler, 2010); however, the few
studies that directly compare psychotherapy and medication tend not
to reveal consistent differences between the two treatments. In contrast
to the findings of Wexler and Cicchetti, a few meta-analytic studies do
find the combination of psychotherapy and medication to be superior
to either alone with regard to outcome (Cuijpers et al., 2014). However,
EFFICACY OF PSYCHOTHERAPY 405
psychotherapy consistently has lower rates of dropout and obviously
fewer medication-rated side effects and the introduction of medication
raises dropout for psychotherapy, although when in combination with
psychotherapy, medication dropout is reduced. Further, much of this
effect for antidepressants is only with those patients who exhibit neu-
rovegative signs; for those patients who do not exhibit neurovegative
signs, the effect size for antidepressant treatment is often around zero.
While the data are unclear whether or not augmenting psychothera-
py with medications is useful or counterindicated, there is strong evi-
dence that the addition of psychotherapy is a useful augment in the
medication treatment of a range of disorders including ADHD, bipolar
disorder (Miklowitz, 2008), and even schizophrenia (Brus, Novakovic,
& Friedberg, 2012; Dixon et al., 2010; Gottdiener, 2006), and moreover,
having good psychotherapeutic skill aids in the prescribing of medica-
tions and increases its effects (Blatt, Sanislow, Zuroff, & Pilkonis, 1996).
CONCLUSION
The under-provision and declining utilization of psychotherapy in
the U.S. is not warranted in light of the strong evidence base for psy-
chotherapy as evidenced in our broad review focused on psychody-
namic psychotherapy as an exemplar. This situation represents a sig-
nificant problem for the implementation of the Affordable Care Act.
We would suggest that to the degree that decreasing reimbursement
for psychotherapy relative to medication fuels declining utilization, the
shift away from psychotherapeutic treatment relative to medication is
“penny wise and pound foolish.” This may be especially pronounced
in relation to the costs incurred, by both patients and society at large, in
the management of complex mental disorders.
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