Another factor to consider is the issue of high-frequency and/or long-term psychotherapies. Some evidence suggests that longer treatments have more lasting effects (Fonagy et al., 2015, 312). The Swedish “panel study” (STOPP, (Sandell et al., 2000) showed “progressive improvement the longer patients were in treatment—impressively strong among patients in psychoanalysis—on self-rating measures of symptom distress and morale.” A German research group (Zimmermann et al., 2015) argues that “both a high dose and the application of psychoanalytic techniques facilitate therapeutic change in patients with major depression” (469). Improvements were observed in depressive symptoms and interpersonal problems. A consistent finding is that after 10 therapy sessions, a large number of patients show clinically significant improvements in symptoms—while more than 50 sessions are required to achieve a “response rate” of 75% (Lambert and Ogles, 2004).

Some studies show a “sleeper effect,” where the effects of high-frequency therapies take longer to manifest but may have longer-lasting effects (Knekt et al., 2011; Falk Leichsenring and Rabung, 2008; Fonagy et al., 2015). This is reasonable to expect as the goals of LTPP (Long-term psychotherapy) and psychoanalysis (defined as “a more intensive form of psychodynamic therapy” according to the American Psychiatry Organization) are not just symptom reduction. The goal is also a restructuring of the personality so that the patient can face future emotional challenges with more flexible psychological defenses, improved self-esteem, and a greater capacity for good and close relationships—in other words, with a greater chance of lasting mental health. This area needs further exploration. A couple of German projects focus on effects such as “personality restructuring.” Beutel et al. (2023) found in a 5-year follow-up of long-term PDT that such effects were greater for PDT than long-term CBT. An ongoing project (Krakau et al., 2023) is investigating the same question. Similarly, a study found more psychological insight in patients in PDT than in CBT (Klug et al., 2021). These are important findings because with personality restructuring and increased insight into one’s own issues, we expect the individual to be better able to handle future difficulties.

A Finnish project evaluates solution-focused psychotherapy (a form of CBT), psychodynamic short-term and long-term psychotherapy, and psychoanalysis (Knekt et al., 2004). A five-year follow-up (Knekt et al., 2011) showed that “psychotherapy gives faster benefits than psychoanalysis, but in the long run psychoanalysis seems to be more effective,” while a 10-year follow-up (Lindfors et al., 2019) did not show such differences. The authors emphasized the importance of the patient achieving “more mature defense mechanisms, a more optimal level of personality organization, more positive self-perception, improved social adaptation, and a sense of coherence.”

The Finnish findings are interesting for another reason. It is sometimes claimed that psychoanalysis and long-term psychotherapy are some kind of “self-fulfillment” or “self-care” for introspective individuals. To me, this is, in plain language, nonsense. PDT, of which one form is called psychoanalysis, is hard and qualified work that two people undertake: the patient because he or she suffers and fails to understand why—but want to find out. The therapist because he or she wants to help the patient understand more deeply and thereby take the helm in his or her own life. Therapy is thus based on a personal commitment from both parties.