Paving the Way to Evidence-Based Psychodynamic Psychotherapy

Manuel Trujillo, MD

Director of Bellevue Hospital & Professor of New York University School of Medicine Department of Psychiatry

This interview was conducted by Peter Cook on May 5, 2006.

Introduction

Dr. Manuel Trujillo first became particularly interested in short-term psychodynamic psychotherapy while Director at the South Beach Psychiatric Center in the 70s in an attempt to facilitate access to high quality therapy services to the many community residents who sought such services from South Beach’s sprawling network of community clinics. His interest continued to grow, and he has been a leader in the field—teaching, researching, and practicing—for many years now. Over the last 10–15 years, Dr. Trujillo has been instrumental in establishing evidence-based psychodynamic therapy and developing new approaches to treat narcissistic problems.

Background

Once the predominant form of psychiatric treatment, psychotherapy suffered with the explosion of effective, tolerable psychopharmacologic agents discovered during the 70s and 80s and other self disorders. Psychodynamic psychotherapy has suffered in comparison to other types of psychotherapy, largely due to the length of treatment and the concordant difficulties in conducting research. Insurance costs have also been a significant factor. Although the proportion of patients treated with psychotherapy as opposed to combination therapy or drugs alone has lately dropped, the overall number of patients treated with psychotherapy has continued to steadily grow, Dr. Trujillo says. Today, some 9 million patients annually are treated with some form of psychotherapy.

Research

“Traditionally,” Dr. Trujillo explains, “psychodynamic psychotherapy has not been subjected to the methodological rigors of the scientific method, and, therefore, never had the proven efficacy of cognitive behavioral and interpersonal therapies.” However, over the last decade, the picture has changed substantially. “We now have a robust body of studies on psychodynamic treatment demonstrating efficacy for the most common disorders, such as anxiety and depression, and complex ones such as personality disorders.”

Much of the change is due to the development of short-duration psychodynamic therapies, of which Dr. Trujillo has been a steadfast champion. “Originally,” he admits, “my interest in shorter-duration therapy was principally in reducing patient waiting lists.” However, he soon saw that focused, effective therapies had a number of other benefits, particularly for research. “Say you have a theory that anxiety reflects repressed anger,” Dr. Trujillo suggests. “To test this in classical psychoanalysis that lasts 7 years or more is very, very difficult. However, if a program of psychodynamic psychotherapy takes only 20–30 sessions, as is certainly feasible with some of our newer techniques, testing becomes quite doable.”

Short-Duration Psychodynamic Psychotherapy

Traditional psychodynamic psychotherapy is based on a conflict model. Symptoms are results conflicts between unconscious drives (eg, for sex or power) and moral views and conscious objectives. Through free association, therapists facilitate the emergence of unconscious conflicts in their patients until, the unconscious made conscious, the patients can resolve the conflicts.

“Therapists practicing one of the newer, shortened techniques of psychodynamic therapy,” Dr. Trujillo explains, “identify barriers to self-knowledge (ie, defenses) in their patients and challenge them actively instead of relying on the slow process of free association to unearth the conflicts.”

In order to facilitate rapid work-through of problems, the therapist creates a focus, or several foci, on which to work. According to Dr. Trujillo, these foci need not be exhaustively crafted anew for each patient, as conflicts tend to organize around clusters of issues such as, conflicts with authority or sibling rivalry.

Benefits of Psychodynamic Psychotherapy

“One of the great strengths of psychodynamic psychotherapy is that most clinicians receive some training in it,” Dr. Trujillo says. “A new psychotherapy may be very successful, but the difficulties in teaching it may be prohibitive to its widespread use. It generally takes very little extra training for a psychiatrist already familiar with psychoanalytic psychodynamics to implement our new techniques.” Not only are shorter-duration treatments friendly to evidence-based medicine, but, as Dr. Trujillo says, “new psychodynamic techniques can act as a laboratory to test psychodynamic hypotheses that have been previously untestable.” Tests of this sort are already underway. “In the past we might wonder: does focusing on transference lead to faster patient improvement? Now we can measure this.”

Treatment

Dr. Trujillo believes that psychodynamic psychotherapy should be considered for front-line treatment of disorders for which its efficacy is comparable to medication and CBT. Evidence demonstrates psychodynamic therapy’s success in treating moderate-to-severe anxiety disorders, social phobia, panic disorder, dysthymia, and personality disorders. There is also strong support in the literature for using psychodynamic therapy in conjunction with psychopharmacology.

The Future

“Two decades ago, with the emergence of safe and effective medications such as Prozac, it looked like psychotherapy might be on its way out,” Dr. Trujillo says. “However, we’ve learned that medication isn’t always the answer. Further, the efficacy of different types of psychotherapy has been established in numerous studies.”

Dr. Trujillo hopes that, as more is learned about shortened psychodynamic therapies, they can be delivered at lower costs and clinicians will zero in on the essential ingredients for effective psychotherapy for particular disorders. He estimates that 10% of patients receiving psychotherapy today are being treated with planned shortened psychodynamic therapies, but if research continues to pour in and treatment becomes increasingly potent, this number might soon be a great deal higher.

Disclosure: Dr. Trujillo reports no affiliation with or financial interests in any organizations that might pose a conflict of interest.