To the Editor: In the January 2011 issue of the Journal (1), Andrew Gerber, M.D., Ph.D., and colleagues from APA's Ad Hoc Committee on Research on Psychiatric Treatments meticulously reviewed the quality of existing randomized controlled trials of psychodynamic psychotherapy and identified important problems in a significant percentage of the studies. However, two issues not specifically addressed by the authors should be highlighted.

The first issue is that randomized controlled trials of psychodynamic psychotherapy have tended to focus on patients with one specific DSM axis I diagnosis, such as depression, generalized anxiety disorder, social phobia, and posttraumatic stress disorder. Symptom-focused studies do not reflect the clinical reality that many patients treated with psychodynamic therapy present with complex problems that may include but are not limited to a single axis I disorder (2). Patients with more complex problems typically require and do better with longer-term psychodynamic psychotherapy. Only 12 of the 94 studies included in the review by Gerber and colleagues evaluated the effects of individual psychodynamic psychotherapy lasting 1 year or longer.

The second issue is that many investigators have questioned whether randomized controlled trials are truly representative of how psychodynamic psychotherapy is actually practiced in the real world. Seasoned clinicians do not adhere strictly to empirically supported techniques prescribed by the manual for their particular school of therapy. The most effective clinicians use a blend of approaches and switch strategies according to the patient's needs at any given moment during treatment (3, 4).

In everyday clinical practice, patients frequently bring more than one illness to therapy, and their therapists often introduce more than one empirically supported treatment in endeavoring to help them.