Mental health problems affect millions of people around the world. These issues can range from common struggles, like anxiety, to more severe and long-lasting conditions that require specialised care. In the UK, about half of those diagnosed with psychosis or schizophrenia need continuous support. Around 15% of them face chronic conditions with little improvement, and 10% may die by suicide (Santesteban-Echarri et al., 2017). Many of these individuals deal with childhood or complex trauma, relationship difficulties, and emotional struggles that short-term therapies cannot improve (Leichsenring et al., 2013).
However, psychodynamic therapy takes a different approach. It focuses on understanding the root causes of interpersonal and mental health difficulties. This type of therapy looks at early life experiences in childhood, emotional patterns, and unconscious thoughts or emotions that may remain hidden (Bellis et al., 2014). Psychodynamic therapy aims higher than to just manage symptoms in the ‘here and now’. It helps people uncover and work through the deeper reasons behind their distress. This can bring lasting change and hope for those facing complex challenges (Lindfors et al., 2015).
A recent study led by Hirschfeld and colleagues examined psychodynamic therapy in the NHS. The study followed patients for over ten years. Could this approach offer an answer to those who need it most? Let us have a closer look at the evidence.
Psychodynamic therapy is long-term approach addressing the deep-rooted causes of severe mental health challenges that short-term treatments often fail to resolve.
Methods
The study by Hirschfeld et al. aimed to examine how psychodynamic therapy works in an NHS service. Over ten years, researchers collected data from 474 people with serious mental health difficulties. All participants completed assessments before and after therapy using a tool called CORE-OM. This tool measured their symptoms, how much pain they felt, and how well they functioned in their daily lives. Therapists also provided detailed reports to track changes and progress.
This study was different from controlled experiments. It adopted a naturalistic study design to show what therapy looks like in the real world, especially within the NHS, which helped to provide a broad understanding of how therapy works in practice. The therapy was customised for each patient. Patients attended weekly sessions over one to two years, depending on what they needed. The study also collected data about how often patients attended sessions and how they responded to the therapy.
Results
Hirschfeld and colleagues found that psychodynamic therapy greatly improved mental health outcomes for people with complex conditions treated in the NHS. The results from CORE-OM showed a clear drop in psychological distress. Before treatment, the average score was 22.7, indicating moderate-to-severe distress. After treatment, the score dropped to 17.8, showing moderate distress. It suggested a meaningful improvement in overall mental health.
According to the results of the pre-treatment test, employment, economic status and medication use, all affected the level of patient distress. Those who were unemployed, chronically ill, disabled or on welfare scored higher than those employed or other. Patients taking medication also scored higher than those not taking it.
The study also found specific areas where patients made progress according to the report of therapists. As for the problem severity, the symptom of depression improved the most. Other issues, like relationship problems, self-esteem, trauma abuse, and interpersonal relationships also improved but at a slower rate, while personality problems changed the least. Therapists reported scores for these conditions which went from moderate to mild. In addition, risk levels related to self-harm and suicidal thoughts decreased. By the end of therapy, many patients’ risk ratings went from mild to no risk.
Moreover, the study emphasised the role of therapy engagement. On average, participants attended 31.7 sessions, with an absence rate of 26%. Those with higher scores at the start of treatment were more likely to be absent. In addition to this, certain groups showed better engagement and outcomes. Women and people living with partners attended more sessions and showed greater improvement than men and those living without partners. Both of the two groups started with higher distress scores and had slightly larger reductions in distress by the end of therapy. It seems regular attendance can lead to planned and successful therapy endings.
These findings show that psychodynamic therapy may be effective for treating complex mental health difficulties and may improve a range of symptoms and functioning.
Psychodynamic therapy significantly reduced psychological distress and suicide risk in people with complex mental health needs, with better outcomes linked to regular attendance and social support.
Conclusion
In conclusion, the study by Hirschfeld et al. found that psychodynamic therapy may help reduce distress and improve the functions of patients facing serious and continued challenges. It is extremely useful for some people who need long-term care and have no response to other therapies. The findings may inspire NHS practices, particularly mainstream secondary mental health services, such as CMHTs, to offer a variety of therapy options to meet different needs – especially when they serve people with presentations of complex trauma.
The authors stated:
Psychodynamic therapy provided within this service seems to be a valuable option for addressing ingrained, complex, and long-standing mental health problems, producing changes in symptoms, wellbeing, functioning, and interpersonal relating.
It offers hope by focusing on in-depth, lasting psychological changes which makes it a strong choice for addressing the needs of individuals with the most complex mental health challenges.
Psychodynamic therapy could be a valuable addition to NHS services for those not helped by other treatment modalities.
Strengths and Limitations
The study’s strengths include its naturalistic design, which reflects the true conditions and challenges of treating patients in everyday public healthcare practice with limited funding and resources. With a large sample size of 474 participants over ten years, it provides strong evidence that psychodynamic therapy can reduce psychological distress and improve wellbeing. The study also combines data from both patient self-reports and therapist evaluations. It gives a more comprehensive view of therapy outcomes and broadens the perspective for interpreting research findings.
However, in my opinion, the study presents weaknesses. Firstly, the lack of a control group makes it hard to say for sure that psychodynamic therapy alone led to the improvements. Studies have shown that family relationships, substance abuse and other issues can affect an individual’s recovery (Gamieldien et al., 2021). Additionally, low socio-economic status is a risk factor for poor mental health (Kivimäki et al., 2020). So other factors, like natural recovery, medication, or changes in the economic situation, could have played a role.
Moreover, the naturalistic design, while useful for real-world insights, also led to differences in data quality. Relying on self-reported measures like CORE-OM could create bias because patients might overestimate or underestimate their symptoms based on their experiences or expectations.
The study also does not explain enough about how factors like patient engagement or dropout rates affected the results. As a reader, you come across a lack of a detailed analysis of how socio-economic status or cultural background influences therapy outcomes to contextualise the findings. Therefore, further research is needed to find out why some patients improved more than others.
Overall, this study reveals the potential of psychodynamic therapy for complex mental health presentations. At the same time, the study shows the need for more rigorous research, like controlled trials, to better understand how effective this approach truly is and how it can be used more widely.
A key limitation is that other factors like medication use, life changes, or socio-economic conditions may have influenced the results, making it hard to attribute improvements to therapy alone.
Implications for practice
Some statistics estimate that the proportion of people with serious mental health difficulties in the UK has increased from 7.9% in 2000 to 9.3% in 2014 (Stansfeld et al., 2016). Thus, the NHS needs to allocate more resources to support people with such presentations. Although research has shown that most patients experiencing acute distress can benefit from short-term psychotherapy (Kopta et al., 1994), it is not sufficient for many patients with chronic distress and complex PTSD. It is, therefore, important to distinguish between patients who benefit adequately from short-term psychotherapy and those who need long-term psychotherapy (Leichsenring & Rabung, 2011). The findings of Hirschfeld et al. give empirical support for mental health professionals to consider psychodynamic therapy as an option for the treatment of complex and long-term conditions. From a political aspect, the study stresses the need to make longer-term and specialised therapies more available within the NHS. Policymakers should invest in long-term therapies, including training therapists/clinical psychologists and expanding access to psychodynamic therapy.
On a personal level, this study strengthened my faith in the power of strong therapeutic relationships. It brought to my mind a patient who shared his struggles with depression, anxiety, and addiction. He was unable to afford medication and did not have family support. Through regular counselling, we built a good working relationship that gave him space to process his feelings and rebuild his confidence. Over time, he expressed gratitude for having a safe place to address past trauma and find emotional stability. While this was not a psychodynamic process, it showed me how such approaches, where clinicians can provide a safe space within time, can help people unpack past experiences. Stories like these indicate the need to make psychodynamic therapy more available to those who need it the most.
The study highlights the urgent need for the NHS to invest in longer-term therapies like psychodynamic therapy, especially for those with complex and enduring difficulties.
King’s MSc in Mental Health Studies
This blog has been written by a student on the Mental Health Studies MSc at King’s College London. A full list of blogs by King’s MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.
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Links
Primary paper
Hirschfeld, R., Steen, S., Dunn, E. L., Hanif, A., & Clarke, L. (2024). The effectiveness of psychodynamic therapy in an NHS psychotherapy service: Outcomes for service-users with complex presentations. Psychoanalytic Psychotherapy, 38(2), 132–152.
Other references
Bellis, M. A., Hughes, K., Leckenby, N., Perkins, C., & Lowey, H. (2014). National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC Medicine, 12(1), 72. 2
Gamieldien, F., Galvaan, R., Myers, B., Syed, Z., & Sorsdahl, K. (2021). Exploration of recovery of people living with severe mental illness (SMI) in low/middle-income countries (LMICs): A scoping review. BMJ Open, 11(3), e045005.
Kivimäki, M., Batty, G. D., Pentti, J., Shipley, M. J., Sipilä, P. N., Nyberg, S. T., Suominen, S. B., Oksanen, T., Stenholm, S., Virtanen, M., Marmot, M. G., Singh-Manoux, A., Brunner, E. J., Lindbohm, J. V., Ferrie, J. E., & Vahtera, J. (2020). Association between socioeconomic status and the development of mental and physical health conditions in adulthood: A multi-cohort study. The Lancet Public Health, 5(3), e140–e149.
Kopta, S. M., Howard, K. I., Lowry, J. L., & Beutler, L. E. (1994). Patterns of symptomatic recovery in psychotherapy. Journal of Consulting and Clinical Psychology, 62(5), 1009–1016.
Leichsenring, F., Abbass, A., Luyten, P., Hilsenroth, M., & Rabung, S. (2013). The Emerging Evidence for Long-Term Psychodynamic Therapy. Psychodynamic Psychiatry, 41(3), 361–384.
Leichsenring, F., & Rabung, S. (2011). Long-term psychodynamic psychotherapy in complex mental disorders: Update of a meta-analysis. The British Journal of Psychiatry, 199(1), 15–22.
Lindfors, O., Knekt, P., Heinonen, E., Härkänen, T., Virtala, E., & the Helsinki Psychotherapy Study Group. (2015). The effectiveness of short- and long-term psychotherapy on personality functioning during a 5-year follow-up. Journal of Affective Disorders, 173, 31–38.
Santesteban-Echarri, O., Paino, M., Rice, S., González-Blanch, C., McGorry, P., Gleeson, J., & Alvarez-Jimenez, M. (2017). Predictors of functional recovery in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies. Clinical Psychology Review, 58, 59–75.
Stansfeld, S., Clark, C., Bebbington, P. E., King, M., Jenkins, R., & Hinchliffe, S. (2016). Common Mental Disorders. NHS Digital.