Feature

At age 7, Pratyusha Tummala-Narra emigrated from India to the United States with her family, leaving behind a country rife with political tensions. Her struggles to adjust to life as a racial and ethnic minority led her to pursue a PhD in psychology from Michigan State University. For the past 20 years, she has worked as a clinician, integrating psychoanalytic, multicultural and feminist perspectives into her practice, which focuses on helping immigrant and ethnic-minority clients deal with acculturation, discrimination and trauma. Her work draws on the ideas of the founder of psychoanalysis, Sigmund Freud, to explore how her clients' thoughts and feelings that may lie outside awareness affect their social, cultural and political experiences.

As controversial as Freud may be, people often forget that he and his colleagues opened free clinics throughout Europe so that people of any class could have access to psychotherapy, says Tummala-Narra, who is also a professor of counseling, developmental and educational psychology at Boston College.

"When psychoanalysis came to the United States in the early 1900s, it developed into a form of treatment that seemed to only be accessible to the middle and upper-middle classes, which was never Freud's intention," she says. "He viewed psychodynamic therapy as a universal treatment for all people."

Once the ruler of the therapy world, psychoanalysis and psychodynamic therapy fell out of favor in the United States among many mental health professionals over the past 40 years, due to several factors. Some experts cite a lack of commitment by psychoanalytic theorists to conduct research on the ther­apy's effectiveness. Others see the treatment as too abstract because it seeks to help clients uncover deeper, often unconscious aspects of experience, while approaches such as cognitive-behavioral therapy (CBT) focus more on helping clients adjust thoughts believed to cause negative emotions. Further, many of Freud's specific ideas, such as the Oedipus complex, have been dropped in favor of a broader view of early relationships and their impacts. And others say psychodynamic therapy is just not relevant or efficient in today's quick-fix, insurance­limited marketplace.

But today's psychoanalytic practitioners say that for many mental health issues, psychodynamic therapy is at least as effective as, if not better than, other therapy approaches—and should not be ignored.

"As a field we've moved into focusing heavily on what are considered to be empirically supported treatments, largely based on protocol and in short-term models of psychotherapy," Tummala-Narra says. "Yet as practitioners, we're seeing patients who are suffering from multiple stressful events in their lives, including homelessness, poverty, trauma and discrimination. Helping them deal with all of these complicated issues really requires a depth of understanding of the whole person and how these events are affecting their relationships with people and how they function in the world. To truly help our clients, we can't always just rely on a protocol-based treatment."

Plus, psychoanalytic thinking has evolved rapidly since Freud, says Jonathan Shedler, PhD, a clinical professor of psychiatry at the University of Colorado School of Medicine who also has a private practice. "The development of psychoanalytic thought did not end with Freud any more than the development of physics ended with Newton, or the development of the behavioral tradition in psychology ended with Watson," Shedler says.

And most important, these practitioners say, a new commitment to science by psychoanalytic researchers and practitioners has led to a growing body of evidence that psychodynamic therapy is as effective as—and sometimes more beneficial than—CBT and other therapies.

Mounting research

Several recent studies have found that psychodynamic theory can provide more long-term benefits than CBT. In 2015, University College London psychoanalyst and clinical psychologist Peter Fonagy, PhD, led a study through the National Health Service in England comparing 18 months of once-a-week psychoanalytic therapy with "treatment as usual," which included CBT, among adults with chronic depression. The researchers found that 18 months of psychoanalysis provided similar benefits in terms of observer-based and self-reported depression scores compared with the control treatment. But the team also found that patients who received psychoanalytic therapy experienced much longer effects: Two years after treatment ended, 44 percent of patients who received psychoanalysis no longer met the criteria for major depression, compared with 10 percent of the CBT group (World Psychiatry, Vol. 14, No. 3, 2015).

A second study, led by Fonagy and published in 2016, looked at parent-infant psychoanalytic psychotherapy, which aims to improve the interaction between parent and child. Participants were randomly assigned to receive parent-infant psychotherapy or supportive primary care. The authors found no significant difference in outcomes for either intervention on measures of infant development, parent-infant interaction or the parent's ability to consider the baby's mental state as well as their own. However, parents who had received parent-infant psychotherapy showed improvements on several measures of maternal mental health, such as less parenting stress and more positive views of themselves as parents (Infant Mental Health Journal, Vol. 37, No. 2, 2016).

Another study published this year, led by Ellen Driessen, PhD, a postdoctoral psychology research associate at VU University in Amsterdam, found that short-term psychodynamic therapy for depression is at least as effective as CBT with regard to many important aspects of patient functioning, including reducing anxiety and pain and improving quality of life (Journal of Consulting and Clinical Psychology, Vol. 85, No. 7, 2017).

"To me, the important thing is finding the psychological therapies that work best for particular patient groups and, to find those treatments, I think we have to have a better understanding of the nature of the problems that people come to us with," Fonagy says. "That's where I think psychoanalysis can help, because it does have a very sophisticated model of the mind."

In a 2010 comprehensive research review, Shedler found that, particularly for common conditions such as anxiety and depression, psychodynamic therapy is at least as effective as all the other therapies that he says are branded and promoted as evidence-based (American Psychologist, Vol. 65, No. 2). Moreover, he says, the benefits of the psychodynamic approach appear to endure much longer than those of CBT.

For example, a 2006 meta-analysis he includes in his review—which was updated in 2014 to include 33 randomized controlled trials of 2,173 patients with a range of common mental disorders—showed a reduction in anxiety and depressive symptoms among participants who received short-term (less than 40 hours) psychodynamic therapy. These benefits continued increasing over time and were actually greater at long-term follow-up, nine months or more after the intervention ended. This suggests that psychodynamic therapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended, Shedler says.

"For the most common conditions, such as anxiety and depression, the benefits of CBT start to dissipate the day the treatment ends," Shedler says. "The typical finding is that by six months to a year, there is no indication that there was any benefit whatsoever."

Not everyone agrees with that assessment. Vanderbilt University psychology professor Steven Hollon, PhD, past president of the Association for Behavioral and Cognitive Therapies, notes that individuals do relapse following successful treatment with either CBT or an antidepressant medication, but prior CBT cuts the relapse rate by more than half, according to a 2013 meta-­analysis he co-­authored (BMJ Open, Vol. 3, No. 4).

"Depression tends to be a chronic or recurrent disorder, so subsequent symptom return is what you would expect, but we have clear evidence that CBT has an enduring effect as compared to medication," Hollon says. "Psychodynamic therapy may have an enduring effect, too, but that has simply never been adequately investigated. Absence of evidence is not evidence of absence, but the approach has been around for over a century and simply has not been all that adequately tested."

Psychoanalytic practice today

One of the greatest misconceptions regarding psychodynamic therapy is that it has remained unchanged since Freud introduced it at the turn of the century, Shedler says.

"There have been sea changes in psychoanalytic theory and technique, but psychology textbooks continue to offer portrayals that are a century out of date," he says. "People still think that patients come in four or five days a week for an hour at a time and lie on a couch," he says.

While a few psychoanalytic therapists still practice that way, today most see their patients once a week. Tummala-Narra says she works with most of her clients once or twice weekly, and that the length of their treatment varies, with some clients lasting several weeks, and others several years.

The approach focuses on helping patients understand themselves more deeply so they can identify the factors underlying their difficulties and stop repeating the same patterns, Shedler says.

"A central way of understanding the psychodynamic approach is that there's more to human beings than meets the eye," he says. "There's what you can see on the surface of things—presenting problems or symptoms or a diagnosis—and there's what is going on psychologically that's underlying the patient's problems."

The approach differs from other therapy techniques in that it seeks to help clients uncover underlying reasons for their feelings and behaviors, which may initially be outside the client's awareness. Other approaches focus more on helping clients adjust unhelpful present thoughts.

"Psychologists who practice psychodynamic therapy are more interested in some of the complexities and subtleties of clinical work, and are less content to define success just in terms of something like lessening symptoms," says Elliot Jurist, PhD, psychology professor at the City University of New York and ­editor of Psychoanalytic Psychology. "They tend to pursue the more ambitious goal of helping someone move toward psychological health, rather than just getting rid of what they're suffering from."

Tummala-Narra focuses her client discussions on past experiences, such as a client's childhood and relationships with family members, as well as present challenges. "As the family is typically the initial space for socialization, I pay close attention to what messages ­clients have learned from parents, siblings, grandparents and other significant people in their life," she says.

She encourages her clients to follow their thoughts wherever they lead, also known as free association, and inquires about early childhood memories and dreams to help facilitate discussion of the meaning of clients' experiences. "Learning about each aspect of experience helps me and the client understand in more depth the nature and history of the current suffering." That, she says, leads to insights that help the client move toward considering and engaging in new, more productive and fulfilling ways of thinking about themselves and others.

Psychodynamic therapy also allows patients to explore and rework their relationships through the therapeutic relationship by examining transference and countertransference dynamics, Tummala-Narra says. For example, the therapist may avoid or minimize the role of racism in the client's life if he or she feels uncomfortable or has conflicted feelings about race and racism, she says. "The client in turn may unconsciously collude with the therapist's discomfort, and minimize the role of racism in his or her life. Working through impasses or enactments of these dynamics is critical to psychoanalytic practice, and offers an opportunity to engage in a unique relationship that promotes authenticity and the ability to tolerate and work through painful affective experiences."

Shedler agrees, noting that this is a crucial dividing line between the psychodynamic perspective and other therapy approaches. "The relationship that the patient creates with the therapist is a window into what goes right and what goes wrong in the patient's other relationships," he says. "We're not just hearing about what causes the person's problems, we're actually experiencing it firsthand in the office."

Looking toward the future

Given the research supporting the effectiveness of psychoanalysis, Jurist says he is hopeful that more practitioners will be open to providing it. "My hope is that this will help reduce the stigma around psychodynamic thinking and that people will take things that they find valuable and use it in their practice," he says.

Jacques Barber, PhD, dean of psychology at Adelphi University, shares Jurist's hope that the growing body of evidence that psychoanalytic therapy is effective will boost interest among researchers and practitioners. Unfortunately, he notes, funding to study psychodynamic therapy in the United States is difficult to come by because it requires a large sample size and can be hard to implement.

"We know that no treatment is effective for all patients," Barber says. "Now the important question is, how do we try to predict what kind of treatment will work best for which kind of patient? I think this is what the next generation will need to deal with."

Tummala-Narra agrees, pointing to the need for those in the profession to enlighten students, professionals and educators about the validity and relevance of psychoanalytic theory in contemporary practice.

"We need to broaden the perspective in terms of what's thought about as effective psychotherapy, rather than relying on one subset of techniques or methods," she says.

Ken Levy, PhD, a clinical psychology professor at Penn State University who maintains a small psychodynamically ­oriented private practice, adds that review panels, journals and psychology departments also need to pay more attention to valuing the idea of diverse thinking and diverse ideas.

"Some of the greatest achievements in psychology have occurred in the context of people having different ideas about things," he says.

For example, Walter Mischel's cognitive-affective personality theory is consistent with psychodynamic models such as object relations and attachment theories.

"Mischel initially saying that there was no such thing as personality led to a resurgence in personality research that now has Mischel as one of the leading frameworks in personality ­theory," Levy says. "That happened because people had differences of opinion."

Additional reading

Cultural Competence as a Core Emphasis of Psychoanalytic Psychotherapy
Tummala-Narra, P.
Psychoanalytic Psychology, 2014

Short-Term Dynamic Therapy vs. Pharmacotherapy for Major Depressive Disorder
Barber, J.P., Barrett, M.S., Gallop, R., Rynn, M., & Rickels, K.
Journal of Clinical Psychiatry, 2012

Psychoanalytic Psychology
www.apadivisions.org/division-39/publications/journal/index.aspx