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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Minding Your Mind Minding Your Mind
 

Psychotherapy That Helps Your Mind and Your Emotions


May 25, 2012

By Michael Craig Miller M.D.

Harvard Medical School


The best psychotherapy helps you learn not just how you think. It helps you understand how your emotions work, too. Ideally, with insight into your emotions, you may find that you are repeating patterns that are making you unhappy.

With the right kind of help, you may be able to take better control of your life and make new choices. You see that you have options you didn't realize you had. This can make you feel more ready to make positive changes.

That's what psychodynamic therapy helps people do. It's a type of talk therapy that's rooted in psychoanalysis, the long-term "talking cure." Like psychoanalysis, this kind of therapy focuses on:

  • Relationships and circumstances during our early lives that continue to affect us as adults
  • Mental processes out of your awareness that may affect how you feel and behave
  • Talking through problems as a way of solving them or at least bearing them

Some experts believe that psychodynamic therapy may be just as effective as cognitive behavioral therapy (CBT), and that its benefits may increase over time. Psychodynamic therapy isn't for everyone, but it may be the right kind of therapy for you.

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How it Works

All psychotherapy depends on a good working relationship between therapist and patient. But in psychodynamic therapy, the "therapeutic alliance" is a key part of the process. Through this relationship the patient:

  • Understands himself better
  • Gains insight into the parts of life that would otherwise be difficult to talk and think about
  • Becomes more mindful of a greater range of thoughts, feelings, perceptions and experiences

Dr. Glen Gabbard, professor of psychiatry and psychoanalysis at Baylor College of Medicine, has called the therapeutic alliance the "envelope" within which psychodynamic therapy takes place.

Whereas CBT focuses on thoughts and beliefs, psychodynamic therapy encourages a patient to talk about feelings as well — including those that are contradictory, threatening or not immediately apparent.

The goal in psychodynamic therapy is not to dwell on the past, but to explore how early life experiences, especially with parents, caregivers, and other authority figures, shape how we look at life and our relationships today. The relationship with the therapist provides a window into a patient's relationships outside the office, and offers an opportunity to recognize and change self-defeating patterns. The goal is to give patients greater freedom to direct their lives.

During a session, the therapist encourages a patient to speak as freely as possible about thoughts, desires, dreams, fears and fantasies as they come to mind. This helps the patient and therapist become aware of thoughts and feelings that might otherwise remain hidden. When necessary, a good therapist frequently directs the patient's attention to issues he's avoiding.

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The Benefits of Psychodynamic Therapy

Randomized controlled studies, the ideal way to evaluate treatments in medicine, support the use of short-term and long-term psychodynamic therapy for many disorders.

The Cochrane Collaboration, an international group of experts, looked at 23 randomized controlled studies involving a total of 1,431 patients. Most of the patients had depression or anxiety. All got short-term psychodynamic therapy (defined in this review as less than 40 hours in duration). When compared with patients not receiving the therapy, patients receiving short-term psychodynamic therapy had significantly greater improvement in their symptoms. Patients were assessed again nine months or more after treatment ended. Symptoms improved even more, suggesting that psychodynamic therapy led to lasting psychological changes.

The Archives of General Psychiatry published an analysis of 17 randomized controlled trials involving patients with a range of disorders. They concluded that patients receiving short-term psychodynamic therapy did significantly better than patients who were receiving no treatment. And they did just as well as patients receiving other kinds of psychotherapy, counseling or support (for example CBT, supportive therapy or interpersonal therapy).

A study in the Journal of the American Medical Association compared long-term psychodynamic therapy with various short-term psychotherapies. It reviewed 11 randomized controlled trials and 12 observational studies (included to show the effect of treatment in real-world settings). The studies enrolled 1,053 patients diagnosed with personality disorders or hard-to-treat mood or anxiety disorders. The analysis showed that long-term psychodynamic therapy significantly helped patients with complex psychiatric disorders. In fact, patients continued improving after therapy ended.

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Challenges and Conclusions

Studies of psychodynamic therapy often involve patients with different diagnoses. This makes it hard to draw conclusions about how effective this approach will be for any specific set of problems. Moreover, many studies lack adequate details about treatment methods. Then there are studies that compare therapy patients to patients who are receiving no treatment. In these studies, we don't actually know how the therapy might have compared to another active treatment.

Yet there is now enough research available to support the claim that psychodynamic therapy is an evidence-based treatment with results similar to or better than those reported for other psychotherapies. The bigger challenge is whether psychodynamic therapy will also prove to be cost-effective.

Psychodynamic therapy stands because its benefits not only endure after therapy ends, but increase with time. This suggests that insights gained during psychodynamic therapy have staying power. The patients may come away with psychological skills that grow stronger as they use them. In other words, for many suffering individuals, this therapy may have a unique value that justifies the cost.

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Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.

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