Editorial

Welcome to the second issue of 2023 which commences with ‘A comprehensive overview of randomized controlled trials of psychodynamic psychotherapies’ by Peter Lilliengren. For many, particularly policy makers such as NICE, Randomized Controlled Trials (RCTs) are currently considered the ‘gold standard’ for evaluating psychosocial interventions including psychodynamic psychotherapies. Psychodynamic psychotherapies have a somewhat unwarranted reputation for lacking such evidence, and Lilliengren sets out to counter this by summarising all available RCTs involving psychodynamic psychotherapies. The article describes a thorough literature search which yielded 298 studies published over the last 55 years. The number of studies has increased over time with over 40% of these published in the last 10 years. Most of the studies were conducted in western countries, evaluating psychodynamic psychotherapies of brief duration (less than 40 sessions) for adults with mood, psychosomatic, anxiety, or personality disorders. The studies used comparative, additive, parametric and dismantling designs and include a total of 374 comparisons. Categorization of the outcomes suggests that psychodynamic psychotherapies typically outperform inactive controls, while comparisons with active treatments, including Cognitive-Behavior Therapy, typically indicate no statistical difference. While the evidence-base for psychodynamic psychotherapies is growing, Lilliengren suggests that there are still major limitations and many research questions yet to be addressed. He highlights a pressing need to disseminate this existing research to policy makers and the general public, as well as integrating the findings into psychodynamic training curricula.

One of the aims of this journal is to present a range of different types of research evidence, and to advocate for the role of alternative methodologies to the RCT in providing evidence for the effectiveness of psychodynamic psychotherapies. To this end, the subsequent articles in this issue employ a variety of methodological approaches. The next article is a service evaluation comparing patients’ service use in the year preceding and following contact with an NHS psychodynamic psychotherapy department. Due to the complex interplay between psychological distress, physical symptoms and care-seeking behaviour, patients’ engagement with a psychotherapy department has the potential either to increase or decrease their use of other services. In ‘Service impact: how patients use mental health and medical services before and after psychodynamic psychotherapy’ Naomi Entwistle, Adam Polnay and Tom Russ investigate changes in the use of other services following engagement with their psychodynamic psychotherapy department. They found no significant changes in the use of other services from before therapy to afterwards for the sample as a whole. However, for sub-groups who made regular use of services at baseline, a full course of psychotherapy (16+ sessions) was associated with a statistically significant reduction in outpatient contacts, both for mental health and medical services. No compensatory changes were found in either A&E or inpatient contacts, suggesting this represents an overall reduction in service use. Due to the study design, it was not possible to establish causality; there may be other reasons for this observed reduction such as natural illness course. These findings tentatively support the existing literature that psychodynamic psychotherapy is associated with a reduction in use of wider services.

The next paper adds to the evidence base for remotely delivered psychodynamic psychotherapies that has been published in this journal since the COVID-19 pandemic (Ahlquist & Yarns, 2022; Ahlström et al., 2022; Maroti et al., 2023; Zoumpouli, 2020). ‘Trainee psychologists’ experiences of learning and conducting psychodynamic therapy via telepsychology’ by Gavin Ivey and Lesley Denmeade uses a qualitative methodology, inductive thematic analysis. Although there is a burgeoning evidence-base for telepsychologies, there has been less focus on psychodynamic therapy, and particularly the experience of trainee psychologists learning and conducting online psychodynamic therapy. This study explored the experiences of trainee clinical psychologists learning and conducting remote psychodynamic therapy using internet video platforms. Semi-structured interviews were conducted with ten Australian trainees who were all completing the psychodynamic component of their clinical psychology training. The interviews addressed their experiences of learning and practising online psychodynamic therapy. Inductive thematic analysis of their responses generated five main themes: (1) technological barriers and their impacts, (2) overcoming telepsychology limitations through awareness and adaptation, (3) benefits of telepsychology, (4) effectiveness of psychodynamic telepsychology, and (5) experience of online psychotherapy learning. The participants reported that the paucity of sensory information, client resistance, distraction, problems maintaining therapy boundaries, supervisor opposition, and technological limitations all made online psychodynamic therapy difficult to conduct and less effective than in-person treatment. However, some participants noted that the anxiety of commencing psychodynamic therapy provision was reduced online, and that the ‘layer of separation’ assisted countertransference management. The authors conclude that despite its inherent limitations, online psychodynamic therapy was perceived to be relatively effective, but requires specific training in adapting traditional psychodynamic techniques. Furthermore, psychodynamic therapy may be effectively learned online, but is an inferior alternative to in-person training.

Our final article uses a single case to illustrate how Transference Focussed Psychotherapy (TFP) can be used to treat Narcissistic Personality Disorder (NPD). NPD is notoriously complex and difficult to treat. Whilst there is no research-based evidence for the specific treatment of NPD, there is an evidence base for psychodynamic psychotherapy approaches to Borderline Personality Disorder which includes TFP. In ‘Treating Narcissistic Personality Disorders: A case illustration of key clinical contributions from Transference Focused Psychotherapy for psychoanalytic practitioners’ Tennyson Lee and Kenneth Levy describe how TFP (a contemporary object relations approach which has been developed to treat patients with a Borderline Personality Organization) can contribute to the treatment of NPD. They introduce the main tenets of TFP, and how TFP views narcissism and narcissistic personality structures. They go on to present a case illustration of key aspects of TFP in the treatment of NPD. These include assessment of personality organization, the treatment contract, transference, countertransference, use of clarification and interpretation, technical neutrality, therapist-centered interpretations, the treatment frame and consideration of the stage of treatment. The authors contextualise this work within public sector services, concluding that TFP can make it more feasible to allocate clinicians to work with patients with NPD under supervision due to the clarity of this manualised approach. Whilst keen not to underestimate the difficulty of treating narcissism, the authors note that TFP has made a major contribution to the understanding and treatment of this condition, bringing together previous work from a number of theoretical traditions and integrating these into a comprehensive approach to the assessment and treatment of narcissism.

Ever since Freud’s seminal works, the single case study has been a favoured methodology amongst psychoanalytically informed practitioners, and this journal has published many examples over the last 40 years. The Association for Psychoanalytic Psychotherapy in the Public Sector (APPPS) seeks to address the recognised weaknesses of the traditional, non-empirical psychoanalytic case report through its ‘Evidence-based psychoanalytic case study-prize’. The APPPS hopes to balance rigour and practicality to set up a progressive and feasible research programme which encourages the development and use of a wide range of established and innovative case study research designs. It aims to stimulate practitioner-led research that can contribute to a database of empirical cases testifying to the effectiveness of psychoanalytic interventions in public sector settings such as the NHS. Do please read the announcement in full, and discuss with your colleagues how you, your students or your training programmes can engage with this endeavour.