Future directions

The evidence regarding the impact of psychotherapy on the brain opens up new lines of investigation to enhance our understanding of psychopathology and treatment. These include the following:

1. the mechanisms of action of psychotherapy;

2. the interrelationships between the mechanisms of action of psychotherapy and medication;

3. a clearer understanding of pathogenesis itself and the malleability of some components of the pathogenetic mechanisms of major psychiatric disorder.

Research is sorely needed on psychodynamic treatments because there is only a modest empirical base for psychodynamic therapy. Many more studies are needed, especially those with a randomized controlled design targeted at specific disorders. Studies investigating extended dynamic therapy of a year or more are needed to demonstrate which patients benefit from the additional investment of time and money. In the current climate of cost containment, practitioners of psychodynamic therapy must take cost-effectiveness into account.

The optimal treatment for many psychiatric patients involves a combination of medication and psychotherapy, but research support for this view is also rather modest. Controlled studies of combined treatment versus single modalities are needed for personality disorders and anxiety disorders. In addition, the role of psychodynamic thinking in compliance problems needs rigorous investigation.

In the meantime, the psychodynamic model continues to enrich the patient's understanding and the psychiatrist's practice. The time-honoured principles elaborated here serve as windows into the murky recesses of the unconscious and illuminate human motivation. They also provide the clinician with a 'second sight' that helps make sense out of bewildering and complex clinical situations.

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