Is Psychodynamic Therapy Evidence-Based?
For prospective clients looking for the right therapist, it would be easy to conclude from a quick scroll through a few websites about psychotherapy that “evidence-based practice” is the thing to look for. From marketing copy to the academic literature, much of the writing available about clinical psychology and psychotherapy uses the phrase “evidence-based” as a hallmark of seriousness, legitimacy, and trustworthiness. The question of whether a therapy is effective is obviously an important one, but beneath it lies more complex questions that I think are equally as relevant: what does it mean for something to be evidence-based, and who decides what counts as evidence?
What is the evidence-base for psychodynamic therapy?
Firstly, let’s begin with the simple question of whether psychodynamic therapy is “evidence-based”. In short, yes - psychodynamic therapy has a robust and growing body of research that supports its efficacy as a treatment for mental health issues. In a landmark 2010 paper published in the American Psychologist, psychologist Jonathan Shedler synthesised decades of outcome research and found that effect sizes for psychodynamic therapy are as large as those reported for other therapies actively promoted as "empirically supported" and "evidence-based,". Shedler highlighted that the perception of psychodynamic therapy as lacking scientific support may reflect selective dissemination of research findings rather than the actual state of the evidence.
This study also documented something particularly interesting for those of us who work in longer-term treatment: patients who receive psychodynamic therapy not only improve over the course of treatment, but they maintain therapeutic gains and actually appear to continue to improve after treatment ends. The implication of these findings is that patients gain something from psychodynamic therapy that they can hold onto and keep using to improve further, even after therapy itself is over.
More recent research has continued in this direction, and has found psychodynamic therapy to be just as effective as established empirically supported treatments, particularly cognitive behavioural therapy and psychopharmacological interventions, for a range of mental health issues (Steinhert et al., 2017; Gonon & Keller, 2021; Smith & Hewitt, 2024;). Extensive and rigorous reviews reliably find that psychodynamic therapy improves symptoms of a wide range of disorders including depression, anxiety, eating disorders, and personality disorders, and that patients maintain these improvements over time (Leichsenring et al., 2023).
What actually counts as evidence-based?
Although it is worth taking this research into account when choosing what kind of treatment we want, or thinking about how we as therapists ourselves practice and gain further training and supervision, it is important to put the notion of evidence-based practice into context. Our scientific evidence base is not a neutral, objective framework that descended from the heavens. Rather, it is a historically situated set of decisions about what counts as knowledge, made largely within a positivist, medically-oriented, Western tradition that privileges certain kinds of questions and certain kinds of answers.
An example of this is the randomised controlled trial, widely considered the gold standard of evidence-based medicine, and by extension evidence-based psychology. Randomised controlled trials are very well-suited to testing whether a specific, manualisable intervention produces measurable symptom reduction over a fixed period. It is much less well-suited to measure what actually happens when one real human being, with a complex history and a constellation of wounds, works with one (also human) therapist to address a range of relational, emotional, and even spiritual or existential questions, perhaps over many years. For anyone looking for a therapist, the latter is far more relevant.
As I have written elsewhere, the scientist-practitioner model that governs clinical psychology training in Australia and much of the Western world characterises the use of evidence — that is, what is already known — as a hallmark of good practice. There is something paradoxical about a framework that names itself after science while simultaneously defining, in advance, which forms of inquiry count. Real scientific thinking is characterised by openness to the unexpected, by a willingness to be surprised, by the acknowledgment of what is not yet known. The conflation of "evidence-based" with "good" has produced, in many clinical settings, precisely the opposite: a closing down of curiosity, a deference to what has been established, and a subtle but persistent pressure on practitioners, and perhaps even their patients, to distrust what they can see and feel in the room about what is really working, or not.
How do I find a therapist that’s right for me?
In real life, an effective therapy is one that both the patient and therapist believe in. It occurs inside a relationship strong enough to hold fluctuations in emotional experience (including ruptures and doubts about the relationship itself) and to survive the inclusion of aspects of the patient’s inner life they have previously been unable to access and share with others. Such relationships are typically characterised by mutual respect and aliveness, that is, a sense that something is really happening. Research on therapist effectiveness also demonstrates that therapists’ individual traits, especially their capacity for closeness, genuine presence, attunement, and most significantly, for tolerating and integrating feedback in areas where they might be missing the mark, are a more powerful predictor of therapy outcome than the type of treatment they offer. Given all of that, finding the right therapist can require some investigation, time, and energy, beyond just choosing a treatment modality that has good science behind it. Like any new connection sought, a good therapy relationship can take time to find, but holding out a little longer to search for the right person can really be worth the wait.
If you’re looking for a therapist (or clinical supervisor) and these ideas make you feel like we might be a good fit, I would love to hear from you. I typically meet new patients for one to two initial sessions to ensure that we both feel like the relationship can be fruitful for you, and worthy of the significant emotional, financial, and energetic investment I recognise that therapy requires.