Depth Psychology: Criticism and which of these apply

I work depth psychology. My responsibility includes both the strengths of the process and its limitations.

The evidence from studies is inconsistent. For depression, short-term psychodynamic and behavioral therapies are, on average, similarly effective; for anxiety disorders, the guidelines primarily recommend cognitive behavioral therapy (CBT). For obsessive-compulsive disorder, there has been a first positive randomized trial short-term psychodynamic therapy; however, CBT with exposure is the best-studied approach and continues to be recommended as the first-line treatment. For post-traumatic stress disorder (PTSD), trauma-focused approaches should be offered.

This text deals with depth psychology-based psychotherapy. Together with analytical psychotherapy, it is one of the psychoanalytically grounded approaches included in the guidelines governing treatment in Germany. Nevertheless, they are two distinct forms of treatment: For adults, individual therapy is limited to a maximum of 100 hours of depth psychology-based treatment, but up to 300 hours of analytical treatment.

Even the international research term „psychodynamic therapy“ does not correspond exactly to the German guideline-based treatment. Many studies examine manualized short-term therapies consisting of 20 to 40 sessions. Their results therefore cannot be readily applied to a treatment lasting 60 to 100 hours.

Guidelines summarize the research and translate it into treatment recommendations. The quality of evidence and the strength of a recommendation are not the same thing. Grade A („should“) indicates a strong recommendation, while Grade B („should“) indicates a recommendation. In addition to the available studies, factors such as benefits, risks, clinical experience, and patient preferences are taken into account.

Randomized controlled trials are particularly important for assessing efficacy. Random assignment reduces systematic differences between groups, but does not eliminate every possible source of bias.

Depression. The National Clinical Practice Guideline for Unipolar Depression, Version 3.2 from July 2023, does not recommend any specific treatment: „To date, there is no evidence supporting differential indications for specific treatments for specific patients with depressive disorders.“ This is not a free pass, however, as the guideline itself includes the following caveat: „However, not every procedure is equally suitable for every patient,“ and an incorrect choice could also lead to a worsening of symptoms. A lack of evidence does not mean that the choice does not matter. According to Recommendation 4-27, this decision should be made during the consultation or in a trial setting.

Anxiety. For anxiety disorders, CBT is the standard of care: the first-line treatment with the highest level of recommendation. That is what it says in the S3 Guideline: Treatment of Anxiety Disorders, Version 2.0 dated April 6, 2021: „Cognitive behavioral therapy (CBT) should be offered (Ia/A).“ Psychodynamic treatment follows, with a recommendation level of B and subject to one condition: it should be offered „if CBT has not proven effective, is not available, or if the informed patient expresses a preference for it.“ This applies equally to panic disorder and agoraphobia, generalized anxiety disorder, and social phobia. Regarding generalized anxiety disorder, the guideline is clear: „Psychodynamic therapy appears to be inferior to CBT.“ The guideline’s own addendum belongs in the same section: „The available studies were conducted over a period of up to 30 hours.“

Compulsion. For obsessive-compulsive disorders, this very evidence is lacking. Statement 4-21 of the S3 Guideline on Obsessive-Compulsive Disorder, Version 2.0 dated June 30, 2022, states: „There is no evidence from randomized controlled trials regarding the effectiveness of these treatments.“ Recommendation 4-1, Grade A: „For obsessive-compulsive disorder, disorder-specific cognitive behavioral therapy (CBT), including exposure, should be offered as the first-line psychotherapy.“

The first-line treatment in accordance with the guidelines therefore remains disorder-specific CBT, including exposure. I have also treated people with obsessive-compulsive disorder using psychodynamic approaches, but I have never presented this approach as being equally well-supported. Understanding individual fears, conflicts, and relationship patterns can be helpful; however, it does not replace transparent information about the more well-established treatment of obsessive-compulsive symptoms.

In the standard textbook on my treatment method, Michael Ermann cites, in addition to early developmental disorders, a genetic predisposition and involvement of the frontal lobe, basal ganglia, and limbic system. He also writes that obsessive-compulsive disorders are chronic, do not resolve spontaneously, and are extremely difficult to treat.

PTSD. The S3 Guideline on Post-Traumatic Stress Disorder In its version dated February 27, 2026, it recommends, with a Grade A rating, a trauma-focused approach in an individual setting and lists five interventions with robust evidence, including Eye Movement Desensitization and Reprocessing (EMDR). Psychodynamic approaches are mentioned only in the research recommendations and among the methods whose effectiveness has not been sufficiently verified. However, many practitioners across all disciplines have additional training in trauma therapy methods.

On average, it is just as effective as established methods: that is the key finding. A meta-analysis of Steinert and colleagues summarized 23 randomized studies involving 2,751 participants with various disorders. In these studies, manualized psychodynamic therapies were statistically equivalent to established comparison treatments in terms of the target symptoms. The meta-analysis of Smith and Hewitt confirmed this finding specifically for depression, immediately after the end of treatment.

The Cochrane Review by Abbass et al. examined 33 studies on short-term psychodynamic therapy. The results suggested an effect, but because the studies were small and varied widely, they should be interpreted with caution.

The blanket assertion that this approach is always just as effective as behavioral therapy is not supported by the available data. A more cautious statement is accurate: For some disorders, manualized psychodynamic therapies achieve, on average, similar improvements in symptoms as established treatments. For other disorders, longer courses of treatment, and specific patient groups, the evidence remains significantly less certain.

Equivalence in symptoms has been demonstrated. None of the major systematic reviews claims superiority in either direction. The body of research underlying this is manageable. Two reviews directly compare my method with others; one compares short-term therapy with a waiting list and standard treatment; and one summarizes the entire field. All four measure symptoms, most using abbreviated versions of manual-based scales. This determines how critics interpret the results, and it is here that the response from proponents of my approach begins: with the measurement scale and the duration of treatment.

An article in the [publication] illustrates just how long-standing and heated this dispute is. Deutsches Ärzteblatt From 2006, titled “Therapeutic Methods: The Denigration of Depth Psychology.” The author criticized behavioral therapy for wrongly portraying itself as superior and claimed that his own approach was supported by sufficient studies across all areas of application. This claim goes beyond the evidence, both then and now.

In 2017, Steinert and colleagues published a review in the *American Journal of Psychiatry* in which they formally assessed 23 randomized trials involving 2,751 patients for equivalence, using a predetermined threshold of g = 0.25. At the end of treatment, the difference was g = -0.153, which was below the threshold. The methodology is noteworthy: representatives from both sides sat together on the working group. The study did not go unchallenged. A rebuttal by Ioana Cristea, Pim Cuijpers, and Florian Naudet, titled „Limited Supporting Evidence and Clinical Relevance,“ appeared in the same journal.

The independent cross-validation study was conducted in 2024 by Smith and Hewitt at the University of British Columbia. In nine studies, they directly compared manualized psychodynamic therapy with manualized behavioral therapy for depression and found a g score of -0.11 at the end of treatment, which is formally equivalent. At the one-year follow-up, the findings were neither equivalent nor different; the available data are insufficient to draw a conclusion at this point.

The Cochrane Review on short-term psychodynamic therapy by Abbass and colleagues includes 33 studies with 2,173 participants; the 2014 version is available and is based on a database search conducted through July 2012. The authors urge caution due to limited data and significant differences among the studies.

A study by the same research group provides the framework: Leichsenring and colleagues In 2022, they analyzed 102 meta-analyses involving 650,514 patients in *World Psychiatry*. Talk therapy and medication are on par there (0.34 versus 0.36); in a direct comparison, the difference is 0.11. The authors refer to a ceiling effect in treatment research. The Institute for Quality and Efficiency in Health Care (IQWiG) states On Depression: „It is currently impossible to say with certainty which procedures are most effective in which situations.“

A gap remains, and it is a significant one. The measurements were based on abbreviated forms as outlined in the manual, with Abbass’s approach limited to a maximum of 40 hours. The German guideline of 60 to 100 hours is not reflected in this. In my experience, the most lasting and profound changes usually occur in the last third of the treatment, once the core issues have been worked through repeatedly.

This accusation is as old as the method itself, and Freud himself wrote it down. In „Constructs in Analysis“ In 1937, he quoted a researcher he held in high regard: „When we present our interpretations to a patient, we are acting toward them according to the notorious principle: “Heads I win, tails you lose.’” If the patient agrees, the interpretation is considered confirmed; if he disagrees, the disagreement is considered Resistance and confirms them as well.

Karl Popper He therefore described psychoanalytic explanations as irrefutable. He was not saying, however, that every one of Freud’s observations was wrong. His objection was directed against claims for which no conceivable counterargument is permitted. Adolf Grünbaum, on the other hand, considered many psychoanalytic assumptions to be fundamentally testable, but doubted that an improvement alone confirms their correctness: it could also result from other factors.

In his textbook, Ermann writes that the psychodynamic hypothesis „can be nothing more than a conjecture at first“ and must be „tested during treatment and revised if necessary.“ And whether interpretations have any effect at all has since been tested using randomized assignments. In 2008, Høglend and colleagues One hundred patients were divided into two groups by random assignment and followed for one year. One group received psychodynamic therapy with Transference Interpretations, —that is, with interpretations of what was happening between the patient and the therapist—compared to others receiving the same therapy without these interpretations. Both groups showed significant improvement, and when averaged across all 100 patients, both approaches performed equally well. It was only when the researchers analyzed the patients’ relationship histories that a difference emerged. Patients who had experienced difficult relationships throughout their lives made greater progress with transference interpretations than without them, and this advantage persisted until the follow-up examination three years after the end of treatment.

The guiding question and the long-term question are two separate questions, and for the second one, there is data that does not count according to the rules of the first. In the Helsinki Study (Knekt et al. 2008) randomly assigned patients to one long-term and two short-term treatment groups, none of which involved behavioral therapy. In the first year, the short-term groups were ahead; after three years, the long-term group was ahead. In 2023, the German long-term study by Beutel and colleagues For chronic depression, long-term psychoanalytic and behavioral therapy lasting five years. In terms of symptoms, both approaches were equally effective; however, in terms of changes in personality structure—specifically the structures Ermann refers to—psychoanalytic treatment was more effective. These studies do not demonstrate any superiority in terms of symptoms.

The fact that psychotherapy has side effects is no trivial matter. These include temporary worsening of symptoms, relationship conflicts, dependence on treatment, and emotional strain resulting from confronting difficult experiences.

It is not possible to reduce the frequency of side effects associated with depth psychology-based treatment to a reliable general figure. Definitions, survey methods, and the patient groups studied vary widely.

In the study by Balder and colleagues, clinicians reported at least one side effect in 33.2 percent of 276 cases; there was no statistically significant difference between psychodynamic therapy and CBT. The severity of the illness, however, was associated with the number of reported side effects. In a differently designed survey by Gerke and colleagues, 15.2 percent of former outpatients reported at least one side effect. The figures are not directly comparable.

Damage caused by errors, breaches of boundaries, or inappropriate treatments must be distinguished from side effects resulting from a properly administered treatment.

Above all: A worsening of symptoms is not a necessary component of successful psychotherapy and there is no evidence that „things are starting to change.“ Temporary stress may occur. If a deterioration persists or becomes severe, the approach must be reviewed promptly and, if necessary, modified.

Things often get worse before they get better. If you look behind the scenes, you’ll feel it more at first. Most people, however, see this as progress and say so: “I’m feeling worse now than before, and I’m glad I’m facing this head-on.” In the process, many come to realize that the source of their distress has been there the whole time and has been affecting them all along.

Pursuant to Section 630e of the German Civil Code (BGB), patients must be provided with clear and understandable information regarding significant risks, prospects for success, and substantially different treatment options.

Some of the objections are valid. The key theoretical concepts are difficult to operationalize, interpretations can become circular, and the research does not adequately reflect long-term treatment in Germany.

The key issue is the question of verifiability. Section 16a, paragraph 1, of the guidelines focuses the procedure on „the unconscious psychodynamics of currently active neurotic conflicts and structural disorders, taking into account transference, countertransference, and resistance.“ These are constructs whose existence is difficult to prove or disprove in individual cases. But it is just as pointless as questioning the spiritual experiences of meditators. It is a question of measurability, which is why psychodynamically based methods have a hard time gaining acceptance in modern science.

Effectiveness can be tested, and it has been tested. For depression and some anxiety disorders, there are randomized trials and meta-analyses. For PTSD, the guidelines clearly favor trauma-focused approaches. For obsessive-compulsive disorder, the first positive trial has been available since 2026, while CBT with exposure has been studied much more extensively. And this is always the case: behavioral therapy approaches are better studied because they are easier to study. This is one reason why psychodynamic approaches are rarely found in research. Imagine you want to be taken seriously as a student, a research assistant at a university, or a professor. In that case, you’d be better off focusing on research areas that can be easily operationalized rather than some abstract constructs about which you know very little, precisely because they are hardly taught at universities anymore.