Reconsidering the Evidence for Exploratory Psychotherapies and Relational Processes

Introduction

Insight and experience have served as organizing principles in the evolution of psychotherapy and have remained fundamental across therapeutic modalities. This is perhaps unsurprising as Albert Ellis and Aaron Beck, two major figures in the development of cognitive psychotherapies, were originally trained in psychoanalysis, while Carl Rogers, who pioneered the humanistic orientation, drew significantly from early analytic experimentations by Sándor Ferenczi and Otto Rank (Kariagina, 2018). Despite these shared roots, the field is marked by diversity in how change is understood. Insights may refer to internal conflicts, irrational beliefs, or dissociated states and may draw from historical experiences or emerge through present-moment awareness.

Evidence-based practice is the integration of the best available research, clinician expertise, and patient preferences (American Psychological Association Presidential Task Force, 2006), yet each pillar remains complex and uniquely impacted by various obstacles. Research findings often face validity limitations, clinician expertise remains vulnerable to bias, and patient preferences may be constrained by misinformation and systemic access issues (Advisory Steering Committee, 2024).

This paper examines the empirical support for analytic and humanistic therapies, focusing on treatment outcomes (do these approaches work?) and change processes (how do they work?). We will advocate for a more inclusive conceptualization of therapeutic evidence that values depth, relationality, and responsiveness.

Efficacy of Psychodynamic Psychotherapies

A growing body of meta-analytic evidence demonstrates that psychoanalytically informed therapy and psychodynamic therapy (PDT) are effective approaches for treating depression, anxiety, trauma, somatic symptoms, and personality disorders with therapeutic gains sustained at follow-up (Barber et al., 2021; Leichsenring et al., 2023). Finally, despite clinical guidelines favoring cognitive behavioral therapy for posttraumatic stress disorder, PDT is often preferred for its tolerability when treating complex trauma. PDT seeks to facilitate meaning-making in relation to the traumatic event and to foster acceptance of the trauma and to the behaviors stemming from it (Paintain & Cassidy, 2018). These findings support PDT as a first-line treatment option. Its emphasis on emotional insight and the therapeutic relationship may be particularly well-suited to individuals with complex, recurrent, or treatment-resistant presentations.

Pluralism in Psychodynamic Modalities

PDT encompasses a diverse set of approaches for brief treatment protocols, tailored to various presentations and goals. Highlighted below are several manualized models evaluated through repeated clinical trials.^[1]

Supportive-Expressive Psychotherapy (SE; Barber et al., 2021; Luborsky, 1984)

• Treatment focus: Increasing self-reflection and recognizing recurring interpersonal patterns.
• Therapist action: Assists patients with identifying core conflictual relationship themes and links them to current relational struggles, balancing supportive and expressive interventions.

Panic-Focused Psychodynamic Psychotherapy (PFPP; Barber et al., 2021; Milrod et al., 1997)

• Treatment focus: Understanding the psychodynamic underpinnings of panic and its consequences.
• Therapist action: Interprets unconscious meanings of panic symptoms, explores conflicts around separation, autonomy, and anger, and works through their manifestations in the transference.

Mentalization-Based Therapy (MBT; Barber et al., 2021; Bateman & Fonagy, 2016)

• Treatment focus: Strengthening the capacity to understand self and others in terms of mental states.
• Therapist action: Actively scaffolds mentalizing by modeling curiosity, clarifying misunderstandings, and keeping affect at a tolerable level in interactions.

Transference-Focused Psychotherapy (TFP; Barber et al., 2021; Yeomans et al., 2015)

• Treatment focus: Restructuring internalized object relations and improving affect regulation.
• Therapist action: Interprets split representations as they emerge in the transference, confronting polarization, and fostering integration of self-states.

Experiential Dynamic Therapies (EDT; Lilliengren et al., 2025; Osimo & Stein, 2012)

• Treatment focus: Unlocking unconscious affect and reducing maladaptive avoidance.
• Therapist action: Directly mobilizes emotion by challenging defenses, encouraging a full experiencing of feeling, and monitoring anxiety regulation.

Interpersonal Therapy (IPT; Cuijpers et al., 2016; Klerman & Weissman, 1994)^[2]

• Treatment focus: Linking psychological distress to interpersonal functioning and role transitions.
• Therapist action: Collaboratively develops an interpersonal formulation, clarifies role disputes/changes, and applies attachment-based strategies within a time-limited frame.

^[1] Though there has been some debate about whether IPT should be considered dynamic, it can be understood as integrative with roots in interpersonal psychoanalysis and attachment theory.

^[2] There are other promising manualized models tested in single trials (Lemma et al., 2024; Safran & Muran, 2000).

Efficacy of Psychoanalysis

Although psychoanalysis remains the most intensive among the depth-oriented treatments, existing research indicates it can produce significant improvements, especially for treatment-resistant conditions (Ambresin et al., 2023). It should also not be considered monolithic, as therapeutic action is variably conceptualized—from drive/conflict (insight-oriented) to relational/attachment (experience-oriented) models.

In a meta-analysis of 14 studies (de Maat et al., 2013), substantial and lasting change was shown in cases of persistent, complex psychopathology. In specific, robust effects were observed in symptom reduction and social and personality functioning improvements, both immediately after termination and at follow-up. However, methodological challenges were noted, including session frequency, treatment length, and lack of randomized control groups. In such meta-analyses, it is underscored that psychoanalytic studies usually rely on small cases or individual reports instead of large samples, while they lack a uniform standard to facilitate recruitment of psychoanalysts. In addition, longitudinal studies face specific obstacles considering the number of sessions, time, and funding costs for research. 

Further, standard measures may not fully capture changes expected in psychoanalysis. Thus, researchers have advocated for greater emphasis on such variables as patient-therapist dynamics, affect regulation, and narrative identity (Leuzinger-Bohleber et al., 2016). In sum, while traditional efficacy research has limitations in evaluating psychoanalysis, existing data and theoretical coherence support its continued relevance. This is especially true for individuals seeking depth, self-understanding, and lasting change.

Humanistic-Experiential Psychotherapies

Humanistic-experiential psychotherapies (HEP) emphasize the centrality of the therapeutic relationship, emotional processing, and personal growth. HEPs aim to foster authenticity, self-awareness, and emotional integration. These therapies are rooted in person-centered values that prioritize experience, agency, and empathy over diagnosis (Greenberg et al., 1998).

A comprehensive meta-analysis of 91 studies found that HEPs are effective across a range of presenting problems (Elliott et al., 2021). They yielded significant gains and HEPs also outperformed treatment-as-usual (namely the non-standardized routine care that patients would normally receive outside the study). Generally, this approach results in significant pre- to post-treatment changes and tends to be more effective compared to groups without treatment. In the comparison study with other active therapies, HEPs were found to be statistically and clinically equivalent (Elliot, 2021). Among the subtypes, emotion-focused therapy (EFT:Greenberg, 2015) emerged as particularly effective, especially for interpersonal difficulties (e.g., unresolved relationship issues, social anxiety, high functioning autism).

Another review of 17 studies supported these findings. In this meta-analysis, Duffy and colleagues (2024) raised concerns about the comparisons of CBT to non-bona fide HEPs in some studies, – often supportive modalities delivered with limited therapeutic intent – which might have biased results undervaluing the effectiveness of bona-fide HEPs. These limitations underscore the need for high-quality randomized controlled trials (RCT) with balanced comparisons and fidelity to treatment models. Nevertheless, the existing evidence affirms HEPs as empirically supported modalities, particularly for patients seeking emotionally-attuned, relational, and process-oriented treatment.

Change Processes, Facilitating Factors, and Therapist Responsiveness

While treatment modality has important implications for treatment outcomes, common relational processes consistently emerge as key predictors (and mechanisms) of change across orientations (Elliott et al., 2023). These processes highlight the interactive nature of psychotherapy and offer a complementary lens to symptom-based efficacy research. It is here that analytic and humanistic principles in particular garner empirical support.

Among the change process variables, the therapeutic relationship is most notable. Meta-analyses on the patient-therapist alliance—often defined as purposeful collaboration and attaining an affective bond (Muran, 2022)—support the therapeutic relationship as a predictive link to outcome (Flückiger et al., 2018). A systematic review has also implicated the alliance as a causal change mechanism (Baier et al., 2020).

A second generation of alliance research has studied therapeutic ruptures (e.g., disagreements) as critical markers (Muran, 2019; Muran & Eubanks, 2020; Safran & Muran, 2000). When identified and addressed, ruptures can serve as opportunities for corrective (or new) relational experiences. A meta-analysis of 11 studies found rupture repair episodes to predict successful treatment outcomes and across various orientations (Eubanks et al., 2018). There is also research demonstrating the effect of training therapists in this respect, namely with regard to alliance building and rupture repair (Muran, 2019). One model in particular, alliance-focused training (AFT: American Psychological Association Emotion Regulation Working Group, 2024), has demonstrated significant promise in improving in-session interpersonal processing related to session impact and treatment outcome (Muran et al., 2018).

Relatedly, therapist responsiveness (i.e., attunement to relational dynamics) is a critical variable. One meta-analytic synthesis (Norcross & Lambert, 2019) identified facilitating factors such as empathy, affirmation, genuineness, and cultural sensitivity as significantly predicting better outcomes. They argue that these factors operate interdependently and are fundamental to responsiveness and efficacy. Empirical research has also consistently identified emotional insight and emotion regulation as critical change processes (American Psychological Association Emotion Regulation Working Group, 2024; Peluso & Freund, 2018). Other studies indicate a strong alliance and high therapist responsiveness can create nurturing conditions for emotional exploration (Elliott et al., 2023; Malin & Pos, 2015).

The change process literature underscores the centrality of the therapeutic relationship—long emphasized by analytic and humanistic traditions—as a key determinant of how psychotherapy is conducted, from alliance formation to rupture repair and through the therapist’s responsiveness to patient’s needs and experiences. This literature also demonstrates the basis for psychotherapy integration and the impossibility of setting definite boundaries between treatment modalities.

Call for Pluralism and Inclusion

The growing body of research on analytic and humanistic therapies offers clear evidence that depth-oriented, relational approaches are both effective and enduring. Yet these therapies remain underrepresented in clinical guidelines, funding priorities, and mainstream academic discourse. This imbalance reflects a misalignment between the values embedded in dominant research paradigms and those upheld by relational and experiential therapies. RCT-focused guidelines privilege short-term symptom models, marginalizing relational therapies and qualitative research despite their capacity to illuminate nuanced therapeutic dynamics and patient experiences.

As noted in a number of initiatives (Advisory Screening Committee, 2024; Levitt et al., 2024), comprehensive evidence-based practice must encompass multiple ways of knowing. This includes recognizing the cultural, relational, and contextual dimensions of therapy and continuous research that reflects diverse orientations. Overrepresentation of certain samples and neglect of culturally sensitive interventions highlight the need to address systemic biases within psychotherapy research.

Therefore, methodological pluralism is clinically necessary. A robust evidence base must account for the range of human experiences and many pathways to change. Integrating qualitative inquiry, prioritizing process research, and supporting therapies that emphasize depth of exploration are essential steps toward a more inclusive and scientifically grounded future. The question is not whether depth-oriented therapies are effective, but rather whether our systems of evaluation are expansive and equitable enough to recognize the full spectrum of therapeutic change.