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

Minding Your Mind Minding Your Mind

The Value of Long-Term Talk Therapy

November 16, 2013

By Michael Craig Miller M.D.

Harvard Medical School

"Talk therapy" has taken a back seat to drug therapy for decades when it comes to treating mental disorders. Drug therapies have been praised as faster, more effective, cheaper and easier. But the celebration may have been premature. Relief from depression, anxiety or other psychological problems is often not as simple as taking a pill. And now there is evidence that talking to a trained therapist is rather helpful.

Insight Is Helpful

One type of talk therapy that has been criticized over the years is long-term "psychodynamic psychotherapy." It is based on the idea — first described by Sigmund Freud more than 100 years ago — that becoming conscious of hidden psychological conflicts can help you feel better.

This kind of therapy takes patience and commitment on the patient's part and considerable skill on the part of the therapist. But it is expensive. And the duration and the complexity of the treatment have made it hard to design studies that would test its effectiveness. That's why insurance companies have shied away and, in some cases, have absolutely refused to pay for it.

But in October 2008, the Journal of the American Medical Association (JAMA) published a first-of-its-kind analysis of long-term therapy. It showed that the approach is effective, especially for patients with complex mental disorders, such as personality disorders and difficult-to-treat anxiety and mood disorders.

The authors reviewed 23 studies of traditional psychodynamic psychotherapy. Treatments lasted at least one year or 50 sessions. About half were randomized controlled trials, the highest standard of evidence. The rest were observational trials. These did not compare results between a treatment group and a control group. Together, the studies included just over 1,000 patients.

Let's look at what makes it difficult to study the value of psychodynamic therapy. The average therapist is unable to create the controlled conditions in his or her office that are necessary for a randomized controlled trial. Observational studies, on the other hand, provide a realistic view of psychotherapy practice, but they do not control for factors (such as age, sex, and life experience) that can affect results.

In the JAMA study, the authors' solution was to include both types of research in their analysis. This would also help them find out how the study design might affect the findings.

The analysis showed that patients with complex mental disorders who received long-term psychodynamic psychotherapy had significantly improved as compared with patients who received shorter therapies. Furthermore, patients continued to improve after therapy ended. The number of therapy sessions, rather than the duration of total treatment, predicted who would respond. And, perhaps disheartening to seasoned clinicians, the therapist's level of experience did not affect the results.

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Putting It in Perspective

These findings should be good news to people considering this kind of psychotherapy. But the review had some limitations:

  • It included a relatively small number of studies and patients.
  • It did not:
    • Define which elements of long-term psychodynamic therapy are most therapeutic.
    • Compare psychodynamic therapy to other psychotherapies (for example, cognitive behavioral therapy). Other kinds of psychotherapy, if provided more intensively or over a longer period of time, might be similarly helpful.
    • Evaluate therapy that was combined with drug treatment.
    • Answer questions about the comparative costs of longer and shorter psychotherapies.

An editorial accompanying the analysis pointed out that until relatively recently, psychodynamic psychotherapy's value has not been established by measuring and comparing actual results. Instead, proponents have relied on its theoretical benefits.

Consistent with the modern aims of psychotherapy research, the JAMA study provides some evidence to support the claims of advocates. It shows that it is difficult, but possible, to prove the intuitive notion that insight is helpful. It is also sobering to have two other intuitive notions confirmed: It takes more than a simple prescription or short-term therapy to treat complex disorders; and sometimes, more really is better.

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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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