Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence

Current Clinical Psychiatry Series Editor Jerrold F. Rosenbaum, MD

For further volumes: http://www.springer.com/series/7634

Raymond A. Levy

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J. Stuart Ablon

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Horst Kächele

Editors

Psychodynamic Psychotherapy Research Evidence-Based Practice and Practice-Based Evidence

Foreword by Robert J. Waldinger

Editors Raymond A. Levy, PsyD Department of Psychiatry Massachusetts General Hospital Harvard Medical School Parkman Street Boston, MA 02114, USA [email protected]

J. Stuart Ablon, PhD Department of Psychiatry Massachusetts General Hospital Harvard Medical School 101 Morrimac Street Boston, MA 02114, USA [email protected]

Horst Kächele, MD, PhD Department of Clinical Psychology and Psychoanalysis International Psychoanalytic University Stromstr. 3 Berlin 10555, Germany [email protected] Series Editor Jerrold F. Rosenbaum Chief of Psychiatry Massachusetts General Hospital Stanley Cobb Professor of Psychiatry Harvard Medical School Boston, MA 02114, USA

ISBN 978-1-60761-791-4 e-ISBN 978-1-60761-792-1 DOI 10.1007/978-1-60761-792-1 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011943750 © Springer Science+Business Media, LLC 2012 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Humana Press, c/o Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Humana Press is part of Springer Science+Business Media (www.springer.com)

To my mother and father and others who have helped me live with passion and conviction. Raymond A. Levy To my mom and dad who have helped so many. I hope this book helps preserve what you value so dearly J. Stuart Ablon I would like to dedicate this book to Helmut Thomä, born on May 6, 1921, on the occasion of his 90th birthday. His 40-year long mentorship in matters of psychoanalysis enabled me to fuse theoretical aspirations, down-to-earth research, and satisfaction in clinical work. Horst Kächele

Foreword

This book helps put to rest a dangerous myth. The myth is that psychodynamic psychotherapy does not work – or, at best, that there is no way to demonstrate its efficacy in treating mental illness. The danger is that this powerful form of treatment could be swept aside in current debates about which forms of mental health care are evidence based and therefore worth making available to those in need. Insurance companies, government agencies, and the pharmaceutical industry all push for mental health care that is brief, intermittent, and focused on quick fixes, despite the fact that many people struggle with emotional difficulties that can only be addressed over time using special psychodynamic skills. Modern psychodynamic therapy provides relief to people who are crippled with fear, haunted by past traumas, caught in repetitive patterns of unhappy relationships, and desperate to end lives of unbearable depression. It is often the only form of mental health care that gets people “unstuck” when other treatments have failed. The science behind this clinical truth is elegantly displayed in this book edited by Dr. Levy, Dr. Ablon, and Dr. Kächele. A broad and rich compendium, Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence brings the reader up to date on the latest developments in research while setting the agenda for further empirical work for decades to come. The chapters in this book, authored by international leaders in the field, provide an overview of our current understanding of how and for whom dynamic psychotherapy works. They also preview cutting-edge methods of studying behavioral and neural responses to psychodynamic interventions that promise to yield fresh and novel understandings of how dynamic treatments bring about therapeutic change. This volume begins appropriately with two major reviews of the evidence base for dynamic psychotherapy. Shedler’s chapter, from the original publication in the American Psychologist, is a rigorous overview of existing research and a critique of the myth that dynamic psychotherapy is not an evidence-based treatment. The chapter by Rabung and Leichsenring – a major update of their 2008 publication in the Journal of the American Medical Association – subjects their original work to stringent follow-up testing and expands upon their rigorous meta-analysis. The fact that these areas were originally discussed in highly prestigious journals at the center of academic discourse in medicine and psychology demonstrates the growing recognition of psychodynamic psychotherapies as empirically supported. An essential question regarding treatment is whether psychodynamic therapy is effective for specific disorders. The book presents chapters that provide evidence for the efficacy of dynamic psychotherapy in treating the particular categories of mental illness that are most prevalent in the population – depression (Huber et al. Taylor) and anxiety (Slavin-Mulford and Hilsenroth) – as well as that most costly of illnesses, borderline personality disorder (Levy et al.). Far from the stereotype that psychodynamic treatments are appropriate only for the “worried well,” a growing body of evidence points to their efficacy in dealing with the most pressing mental health problems of our time. Moreover, this book includes documentation of evidence that psychodynamic therapies foster enduring change that may decrease vulnerability to relapse. vii

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New methods allow us to investigate questions that were never dreamed of when psychodynamic treatments were developed or were at best only the subject of speculation. Chapters in this volume provide clear, accessible, and erudite discussions of tools in the domains of neuroimaging, brain chemistry, and cognitive science that are furthering our understanding of how the human mind processes thoughts and emotions in both adaptive and maladaptive ways. Although in its infancy, social neuroscience has begun to shed new light on such core aspects of psychodynamic theory as the unconscious and transference. Moreover, psychodynamic theory informs creative uses of these new technologies to study concepts such as empathy and attachment. The most interesting question in the field is no longer whether dynamic psychotherapy works but how it works. The search for mechanisms or “active ingredients” that bring about therapeutic change has led investigators down a variety of creative and fruitful paths. Process research, once the province of single-case studies, can now be carried out on larger numbers of patients and treatment sessions using sophisticated methods that have been part of the research conversation for more than a quarter century. In this volume, Smith-Hansen and colleagues review this work and chart new avenues for future research. Other chapters focus on the particular roles of transference interpretation, attachment, the therapeutic alliance, and defense interpretation in fostering therapeutic change. The very foundations of psychotherapy research are called into question in a provocative chapter by Luyten et al. They point out that many of the assumptions of prior psychotherapy studies are borrowed from drug trials and do not adequately address issues specific to talking therapies. They call for a new research paradigm that encompasses a dialectic between relatedness and self-definition that they posit to be at the core of human development. The editors have wisely included an entire section on single-case studies. To be sure, modern empirical methods have shed light on the limitations of single-case approaches to understanding treatment. Indeed, concepts such as the “schizophrenogenic mother” grew out of work with individual patients that were never submitted to rigorous empirical tests before being used to inform treatment. Such unfortunate episodes in the history of mental health have prompted many to recoil from individual case studies. However, such an extreme reaction risks throwing out the proverbial baby with the bath water. The fact remains that many of the most creative and innovative hypotheses that are eventually verified by empirical research are born in the consulting room out of practitioners’ work with individual patients. Levy, Ablon, and Kächele include chapters that describe innovative approaches to single-case study and in this way make the clear statement that this mode of generating new knowledge remains a legitimate and vital part of psychotherapy research. Finally, the book incorporates chapters that explain state-of-the-art methods for assessing change in psychodynamic therapy. Such measurement tools are essential to our efforts to increase the evidence base for psychodynamic treatments of all varieties. Moreover, they offer the potential to challenge our preconceptions of what constitutes change in therapy and how it is fostered. In the future, we would do well to expand our work on change to study how it is that different active ingredients – be they transference interpretations, replacement of dysfunctional automatic thoughts, or fluoxetine – can offer relief to people suffering from the same ailments. It is here that frameworks such as dynamical systems theory (chaos theory) may help us understand illness and maladaptive behaviors as “attractor states” that may be disrupted and reorganized by any of a number of interventions [1]. Of course, we will welcome the day when the case for the efficacy of psychodynamic psychotherapy no longer needs to be made. We will welcome a time when scientists, practitioners, and policy makers no longer need to be introduced to or reminded of the empirical support for this powerful form of mental health care. In the meantime, books such as this one are invaluable resources for students, practitioners, and researchers alike. Robert J. Waldinger, MD Associate Professor of Psychiatry, Harvard Medical School Director, Center for Psychodynamic Therapy and Research, Massachusetts General Hospital Director, Laboratory of Adult Development, Massachusetts General Hospital

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Reference 1. Thelen E, Smith LB, Lerner RM, Damon W. Dynamic systems theories. In: Handbook of child psychology. Theoretical models of human development. Vol 1, 6th ed. Hoboken: Wiley; 2006. pp 258–312.

Preface

The Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence continues the important work of our first book published in 2009 (Handbook of EvidenceBased Psychodynamic Psychotherapy: Bridging the Gap Between Science and Practice), presenting in one volume significant developments in research in psychodynamic psychotherapy by excellent clinician researchers. The demand for ongoing research initiatives in psychodynamic psychotherapy from both internal and external sources has increased in recent years, and this volume continues to demonstrate the efficacy and effectiveness of a psychodynamic approach to psychotherapeutic interventions in the treatment of psychological problems. Research continues to help all clinicians think critically about our clinical interventions so we can avoid losing ourselves in our subjectively preferred ideas and concepts without empirical support. Psychotherapy in general and psychodynamic psychotherapy specifically need to sustain their involvement in the evidence-based movement within the larger healthcare system. We recognize and value the importance of clinical supervision in refining and validating interventions within psychodynamic psychotherapy, and we offer the work in this volume in the spirit of ongoing discussion between researchers and clinicians about the value of specific approaches to specific patients with specific psychiatric and psychological problems. Multiple forms of treatment interventions have been developed over the past 50 years, and we support the current emphasis on personalized medicine. We offer the work in this volume in the spirit of including psychodynamic psychotherapy in the effort to advance understanding of finding the right treatment for the right patient. Boston, MA, USA Boston, MA, USA Berlin, Germany

Raymond A. Levy, PsyD J. Stuart Ablon, PhD Horst Kächele, MD, PhD

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Acknowledgments

We are pleased to once again thank many supporters of our work in the Department of Psychiatry at Massachusetts General Hospital. Dr. Jerrold Rosenbaum, the Series Editor, has continued to assist our efforts in creating this volume specifically and has also led efforts to develop the practice, teaching, and study of psychodynamic psychotherapy within the department. Toward this end, we are excited that Dr. Bob Waldinger, who wrote the Foreword to this volume, has joined our department as Director of the Center for Psychodynamic Therapy and Research. We are grateful to the larger psychodynamic community, which has welcomed our first volume and encouraged us to continue our efforts resulting in this follow-up volume. The international community of psychodynamic clinicians and researchers, represented by more than 500 active members of a psychodynamic psychotherapy research listserv, has demonstrated sustained interest in the work of this book. Springer Science + Business Media and our Editor, Richard Lansing, have encouraged us to produce this volume and offered the opportunity to continue our efforts in a series of follow-up volumes over the next years. We are pleased with their support and their successful efforts to promote the book around the globe. Our Psychotherapy Research Program seminar has stimulated ideas, questioned some current psychodynamic wisdom, and encouraged us to continue to publish psychodynamic research that refines current practice. We appreciate the interest of Jeremy Nahum, John Kelley, Helen Riess, Josh Roffman, and Ira Lable. Special thanks to Josh Roffman, for volunteering his time reviewing the neuroscience chapters that have been included. Thanks to Horst Kächele: this volume includes much work from European researchers who have labored over the years to produce research that has perhaps not been adequately recognized in the United States. And, of course, we are grateful to the committed clinician researchers whose life work comprises the chapters included in this volume. We know firsthand how arduous and at time thankless this crucial work is, so we are glad to showcase the work of such talented and committed professionals. We appreciate the continued contributions of those who offered chapters in 2009 and welcome the new authors. Boston, MA, USA Boston, MA, USA Berlin, Germany

Raymond A. Levy, PsyD J. Stuart Ablon, PhD Horst Kächele, MD, PhD

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Psychodynamic Psychotherapy Research: Process, Outcome, and the Brain

This second volume of empirical research in psychodynamic psychotherapy attests to the enduring efforts of an international group of dedicated clinician researchers intent on studying modern psychodynamic psychotherapy approaches to relieving suffering for many patients. This volume follows in a long tradition of books that have offered evidence of the efficacy and effectiveness of psychodynamic psychotherapy treatment [1–7]. The book includes several chapters reflecting research that is currently being conducted in Europe. We are grateful to Horst Kächele who is responsible for helping to include much of this work, probably long overdue in the United States. Before presenting a review of the chapters in the book, it is important to note that the psychotherapy research culture remains controversial, filled with scientific and political tension. The controversy reflects differing opinions about what research designs and, therefore, research findings should be considered legitimate science. Controversy also hovers around whether psychodynamic treatment deserves a place at the table in an era of emphasis on brain-based interventions. Some in the research community still believe that only randomized controlled trials (RCTs) represent legitimate tests of treatment efficacy. In the past decade, the prominence of the RCTs as the design of choice has spawned numerous manualized treatments that can be tested in short-term therapy trials. At its worst, this type of either-or thinking leads to narrow definitions of which treatments should be considered empirically supported, empirically validated, or evidence based. Many clinicians and researchers, including ourselves, have vehemently opposed such a singular view. Among them, Wachtel [8] states, “These criteria, moreover, were remarkably tendentious, a set of standards that constituted an ideological litmus test much more than any genuine requirement of adherence to the scientific method…the problem was not that the various task forces that advocated for these shifting labels and fixed criteria were attempting to impose scientific discipline on an unwilling, antiscientific community of practitioners; it was that the recommendations of these task forces were not sufficiently respectful of the canons of science.” Both our previous volume and this current volume are testimonies to the importance of considering multiple methods and research designs to inform clinicians making treatment decisions. Both RCTs and naturalistic designs are flawed and yet both have made significant contributions to the literature and knowledge base about what works for whom. Perhaps the most important question that psychotherapy researchers have been struggling with is not what works for whom, but why and how a given treatment works. Psychotherapy process research remains our primary interest and has emerged as a significant focus of much psychodynamic research recently. Examining the specifics of what actually occurs within a treatment hour as determined by objective raters and relating these processes to outcome hold the most promise for unlocking the mysteries of the very effective intervention we call psychotherapy. Through decades of diligent process research, the importance of the therapeutic relationship has emerged as the primary process

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indicator and predictor of successful treatment [5, 9, 10]. (See Chapters 21, 23, and 24 in this volume.) However, researchers and clinicians alike still struggle with the question of whether the salient variables in all treatments are common factors which are responsible for change in psychotherapy. As this book attests to, as researchers, we continue our search for the therapeutic action of treatments, for the active ingredients that lead to change. Many clinician researchers now agree that the emphasis of future research should be on isolating the principles and interventions of effective psychotherapy treatments [8, 11–13]. We are hopeful that research in psychodynamic psychotherapy and psychotherapy in general will continue to move further away from strict adherence to singular schools of thought in favor of research aimed at determining the treatment processes that lead to sustained change [14]. In Chapter 23 by Smith-Hansen et al. on process research in this book, we make several recommendations for future research, drawing on ideas of Kazdin [13] and Luyten’s Commentary on the coming of age of psychoanalytic treatment for the section on Theory, Technique, and Process in this book. In order to move the field forward in attempting to develop evidence-based interventions that will lead to treatment processes that sustain change in our patients, we recommend: 1. Examining treatment process in both manualized and naturalistic treatments, both in single-case and group-level studies. 2. Using theory as a guide and testing theoretically powerful questions. 3. Including more frequent measurements during treatments in order to examine change over time (e.g., what changes first, what changes next) and including extended follow-up periods to capture changes occurring after termination. 4. Examining the role of multiple possible mediators and mechanisms in a single study. 5. Developing models that capture the complex interactions of relational and technical factors. 6. Using sophisticated statistical models as alternative methods for examining issues related to causation. 7. Examining the bi-directional, reciprocal influences between therapist and patient in contrast to an outdated notion that the therapist exerts a unidirectional influence on the patient. 8. Developing paradigms to study therapist responsiveness to pre-existing patient characteristics and to moment-to-moment changes in the session. As Jorgensen [14] has reminded us, “It is impossible to pinpoint any single factor that is crucial in every therapy. What is needed is a non-dogmatic, multiple factor model that successfully incorporates the knowledge obtained from the many existing theories of psychotherapy-induced change.” The current volume provides wonderful examples of how such recommendations can be applied to the study of multiple populations and problems. If a focus on RCTs defined the previous decade of psychotherapy research and a focus on process research defines the current decade, then an emphasis on genetics and neuroscience will likely define the decade to come. Determined not to be late to the game this time, it is crucial for psychodynamic psychotherapy to stake its rightful claim as a brain-based treatment. We, therefore, emphasize in this volume the contributions of several researchers who do just that. The reader will find up-to-date sections on: Outcome Research; Theory, Technique, and Process; Single-Case Studies; and Assessing Change. They all include novel designs and thought-provoking results. Besides, the reader will also find a rich section on Neurobiology of Psychotherapy that includes coverage of neuroimaging and biomarkers, discussing cutting-edge studies offering the possibility of understanding how the brain is affected by interventions based on psychodynamic principles and treatment techniques. Finally, the reader will enjoy useful appendices containing new and updated measures and practical information.

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Outcome Research The section on Outcome Research includes two meta-analyses, one by Shedler and one by Rabung and Leichsenring, which provide clear evidence of the efficacy of psychodynamic psychotherapy. Rabung and Leichsenring’s chapter emphasizes treatments in long-term psychodynamic psychotherapy and follows their earlier meta-analysis of short-term psychodynamic treatments that appeared in our first volume. Shedler’s chapter solidifies the claim that “empirical evidence supports the efficacy of psychodynamic psychotherapy.” The two chapters in this volume and the earlier work on short-term treatments provide empirical data in support of psychodynamic psychotherapy as an equal to other evidence-based treatment orientations. Several chapters support the claims that psychodynamic psychotherapy is helpful to patients in psychological distress, and Shedler’s chapter solidifies the claim empirically, demonstrating effect sizes equal to those of other treatment orientations. Further review of the important chapters in this section is very thoroughly done in Jeremy Safran and Alexandra Shaker’s excellent invited Commentary.

Theory, Technique, and Process Patrick Luyten, in his invited Commentary of the Theory, Technique, and Process section, points out that “as is demonstrated in each of these chapters, psychoanalytic treatment research not only may inform clinical practice, but also has the potential to change psychoanalytic practice. In fact, there is no point in denying that psychoanalytic practice has already changed under the influence of research findings, both explicitly and implicitly, and will continue to be changed by research.” Luyten invites us to read each of the chapters with eager anticipation as he believes that each reflects “the coming of age of psychoanalytic treatment research.” Luyten’s Commentary reviews each chapter while placing it in the larger context of the intensifying emphasis on process research. He connects the chapters to other research initiatives and findings in his sweeping review of their meaning for psychodynamic psychotherapy treatments. He also includes an important section on implications for psychoanalytic research and training. In their chapter, Wong and Hayward teach us about implicit emotional learning as the foundation of psychoanalytic treatment, partially through the use of a clinical case to demonstrate their research findings. The chapter integrates learning theory with psychoanalytic principles.

Single-Case Studies Three chapters reflect the added value of research to traditional intensive supervisory efforts when studying a single psychoanalytic case. As Fonagy and Moran [15] said in 1993, “The attention to repeated observations, more than any other single factor, permits knowledge to be drawn from the individual case and has the power to eliminate plausible alternative explanations.” Horst Kächele, one of the earliest psychoanalyst researchers, offers an in-depth understanding of the entirety of a psychoanalytic case with over 500 sessions. In their writing, Kächele, Schachter, and Thomä, all psychoanalysts, create a research chapter with analysts’ emotional sensibilities. We are treated to multiple levels of intensive empirical analysis of variables of interest to analytic thinkers and clinicians. In the process, we feel inspired to make use of tape recordings of psychoanalyses and longterm psychodynamic psychotherapies. This chapter will be riveting for any analytic or dynamic thinker interested in learning about the value of empirical research for clinical practice.

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R. Levy et al. demonstrate the richness of the understanding of the therapeutic process of a single psychotherapy session using an empirical measure, the Psychotherapy Process Q-set [16]. The chapter also offers a partial explanation of the rating procedure and the thinking of the particular raters, R. Levy and Ablon. Katzenstein et al. utilize the Psychotherapy Process Q-set to conduct an intensive empirical study of a long-term psychotherapy treatment that reveals specific patient–therapist repetitive interaction structures that are critical to positive outcome. Of course, patient and therapist have their subjective ideas about the critical components of the therapy, but the chapter offers the view of an impartial other. Interestingly, in this case, there are verbatim statements from the patient that suggest her idea about the critical processes that helped her change conforms to that of the research team.

Assessing Change The Assessing Change section contains three chapters that focus on specific instruments available to researchers. Siefert and DeFife provide a helpful guide to new researchers by describing ten particularly useful outcome measures commonly used in psychotherapy research. DeFife and Westen discuss the current debate about the use of objective research measures in assessing patients, in this case patients with personality disorders, during the initial evaluation. They end by suggesting a structured clinical interview for assessing patients with personality disorders that they believe contributes to an effective treatment approach. And Hörz et al. introduce the Structured Clinical Interview of Personality Organization, derived from Kernberg’s ideas, that has been shown to be effective in assessing severity and change in personality pathology.

Neuroimaging, Biomarkers, and Neurobiology As Roffman, Gerber, and Glick state in their chapter, “Despite decades of parallel progress in psychodynamic psychotherapy and neuroscientific research, until recently, there was little meaningful interaction between these fields of study… In the last ten years, though, a remarkable synergy between these fields has begun to emerge, with powerful (and overwhelmingly positive) implications for the future of psychotherapy.” Toward this end, the section on Neurobiology of Psychotherapy contains two reviews of findings from neuroimaging studies. Roffman, Gerber, and Glick completely update their chapter from our first book and take us on a tour of broad-based psychotherapy-related neuroimaging findings. After reporting the updated findings, they discuss the implications for the future of psychotherapy. Viamontes’ chapter reviews neuroimaging findings with a focus on the neurobiology of emotions and memory and then specifically discusses the neural substrates of adaptive change in psychotherapy. These two chapters complement each other well and offer the reader an interesting brain-based view into the future. Eric Kandel [17] has recently stated that “Analysis is the most elaborate and nuanced view of the mind that we have….But analysis is not empirical and we need independent evidence for two points – whether it works (under what circumstances and for whom), and, if so, how it works, that is, what alteration does it produce in the brain? Neurobiology should join forces with psychoanalysis to do this. I think it would be an enormous advance.” In a chapter from a group of Finnish researchers, Lehtonen et al. report on the effects of psychodynamic psychotherapy on the serotonin transport (SERT) function in depressive patients. Lehtonen et al. state that “these findings warrant a conclusion that there is a sub-group of patients in the major depression spectrum, especially those showing signs of rejection sensitivity and other atypical symptoms, whose responses to dynamic psychotherapy are reflected in an increase in SERT binding. Patients with classic symptoms of major depression show similar clinical improvement, but no

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changes in SERT binding.” Although the findings emerge from a study with very few subjects, the suggestion that dynamic psychotherapy has an impact at the molecular level is an exciting one for the future of research and for the enduring value of dynamic treatment. And, in a brief chapter, again from Finland, Karlsson’s 2010 PET study demonstrates an increase in serotonin 1A receptors after 6 months of psychodynamic psychotherapy, whereas a control group treated with SSRIs did not show serotonin receptor changes. Of course, we cannot draw firm conclusions from this penetrating and innovative work, but the findings indicate that psychotherapy has a direct impact on the brain in at least some depressed patients. And, as Karlsson states, “the artificial separation between interventions targeting either brain or mind is outdated. Psychotherapy clearly changes brain functions and there is evidence that medication changes abilities traditionally considered to belong to the mind as distinct from the brain.” In a study with similar aims described the chapter by Ghaznavi et al., psychodynamic psychotherapy research is shown to be central to the larger field of psychiatry. The study hopes to determine the specific areas of the brain that are affected by psychodynamic psychotherapy interventions, in this case a 16-session manualized CCRT treatment for depression. The eventual aim is to identify biomarkers in patients that suggest that treatments based on psychodynamic principles have an increased likelihood of being helpful. If neuroimaging of subjects discovers specific, repetitive pathways in the brain that are affected differentially in patients, it would be possible to determine which patients are pre-disposed toward psychodynamic treatments by administering relatively simple neuroimaging pre-tests. It is the hope of Ghaznavi, Witte, Levy, and Roffman that findings will bring us closer to the aims of the new emphasis on personalized medicine, i.e., finding the right treatment for the right person. In a further brain-based chapter, Glen Gabbard takes us on a tour of neurobiologically based treatment principles for patients with Borderline Personality Disorder (BPD). This accessible and applicable chapter reminds us that the characteristics of such patients often derive from early childhood trauma, which demands that psychotherapy treatments be sustained over an extended period of time. Gabbard expertly reviews the principles and interventions that can be utilized in current treatments based on our knowledge of brain function in patients with BPD. In a related chapter, Buchheim et al. report findings on neural correlates of attachment dysregulation from studies with BPD patients. Buchheim and her colleagues also suggest that the specific neural findings may provide evidence of the possible mechanisms related to the fearful intolerance of aloneness in these patients. Finally, Andrew Gerber, in his invited Commentary on the chapters in the Neurobiology of Psychotherapy section, offers three principle mechanisms of action in psychotherapy, anchored in what he says is known about both psychotherapeutic change and neural mechanisms of learning. He also warns us about five common pitfalls in the use of neuroimaging studies in making statements relevant to psychotherapy. His Commentary functions as an overview of the current state of research and a view into one expert’s suggestions for future research initiatives. It is clearly an exciting time for the collaboration of psychodynamic psychotherapy and neuroscience. This research is only one way in which psychodynamic psychotherapy has taken its place in the search to discover the right treatment for the right person.

Appendices Finally, there are two important appendices that add further interest and value to this collection. The first displays the Child Psychotherapy Q-set, (CPQ) published for the first time in English by Celeste Schneider, a student of Enrico Jones, as well as the adult version of the Psychotherapy Process Q-set, revised in April 2009, by the members of our Psychotherapy Research Program in the Department of Psychiatry at Massachusetts General Hospital. The revised PQS-R is also published for the first time.

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The second appendix, a list of Manualized Treatments in psychodynamic psychotherapy that have been used for research purposes, is introduced by Kächele et al., who reviews the history and role of manualized treatments. They conclude with a clear statement that our clinical judgment must have the last word in determining the appropriateness of treatments rather than allowing adherence to strict empirical research findings to be the final factor in treatment choice.

Conclusion We hope these chapters stimulate ideas and questions and lead to further important research. And we hope that clinician researchers will be inspired by the hard work and complex findings embedded in this volume. We three editors feel inspired by the efforts of our contributors and appreciate the willingness of all to participate. We hope the book stands as a call to action for further research in the spirit of finding the right treatments for the right people. Our capacity to improve our ability to help patients thrive and be relieved of psychological distress depends on such efforts. Raymond A. Levy, PsyD J. Stuart Ablon, PhD

References 1. Hubble MA, Duncan BL, Miller SD. The heart and soul of change: what works in therapy. Washington, DC: American Psychological Association; 1999. 2. Lamb W, Jones E. The effectiveness of psychoanalysis and longer-term psychodynamic psychotherapy: a metaanalysis. Paper presented at the American Psychoanalytic Association meeting, Jan 2009. 3. Leichsenring F, Rabung S. Analyzing effectiveness of long-term psychodynamic psychotherapy. J Am Med Assoc. 2008; 300: 1551–1565. 4. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010; 65: 98–109. 5. Wampold BE. The great psychotherapy debate: models, methods, and finding. 2nd ed. New York: Routledge; 2008. 6. Levy R, Ablon SJ. Handbook of evidence-based psychodynamic psychotherapy: bridging the gap between science and practice. New York: Springer Science + Business Media; 2009. 7. Leichsenring F. Are psychodynamic and psychoanalytic therapies effective? A review of empirical data. Int J Psychoanal. 2005; 86: 841–868. 8. Wachtel PL. Beyond “ESTs”: problematic assumptions in the pursuit of evidence-based practice. Psychoanal Psychol. 2010; 27: 251–272. 9. Safran JD, Muran CJ, Proskurov B. Alliance, negotiation and rupture resolution. In: Levy RA, Ablon JS, editors. Handbook of evidence-based psychodynamic psychotherapy: bridging the gap between science and practice. New York: Springer Science + Business Media; 2009. 10. Beutler LE, Castonguay LG, Follette WC. Therapeutic factors in dysphoric disorders. J Clin Psychol. 2006; 62: 639–647. 11. Blatt SJ, Luyten P. Reactivating the psychodynamic approach to classify psychopathology. In: Millon T, Kuegar R, Simonsen E, editors. Contemporary directions in psychopathology: toward the DSM-V, ICD-11, and beyond. New York: Guilford Press; 2010. pp 483–513. 12. Blatt SJ, Zuroff DC, Hawley LL, Auerbach JS. Predictors of sustained therapeutic change. Psychother Res. 2010; 20: 37–54. 13. Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annu Rev Clin Psychol. 2007; 3: 1–27. 14. Jorgensen CR. Active ingredients in individual psychotherapy: searching for common factors. PSA Psychol. 2004; 24: 516. 15. Fonagy P, Moran G. Selecting single case research designs for clinicians. In: Miller NE, Luborsky L, Barber JP, Docherty JP, editors. Psychodynamic treatment research: a handbook for clinical practice. New York: Basic Books; 1993. pp 62–95. 16. Jones EE. Therapeutic action: a guide to psychoanalytic therapy. Northvale: Aronson & Co; 2000. 17. Arehart-Treichel J. Analysis can use dose of neuroscience, says Kandel. Psychiatr News. March 4, 2011; 46(5):1.

Introduction, Part II

European Psychotherapy Research: The History, the Current State, and Recommendations for the Future

The dating of the beginning of systematic psychodynamic psychotherapy research may depend on one’s outlook on what constitutes research. Freud and Breuer were explorers charting new territory when they published the case studies on hysteria in 1895. However, Freud was aware of the necessity of systematic data collection when, in the 1920s, he asked his disciples to collect many deeply analyzed cases to prove the point he attacked Jung on [1]. The development of a scientific field of psychodynamic psychotherapy research can be dated to the year 1930 when the psychoanalyst Fenichel produced 10-year outcome statistics on more than 700 patients being treated at the Berlin Psychoanalytic Institute based on therapists’ evaluations [2]. The British Medical Journal discussed psychotherapy outcome as early as 1935, reporting on 500 cases [3]. However, before the field really started to blossom, the shadows and nightmares of the Hitler Regime all over Europe – except Britain – wiped out the early tentative steps, and made qualified academics from psychiatry and psychology leave the burned ground and settle in large numbers in North America. In post-war continental Europe, psychotherapy has been very much involved in fighting the sequelae of the war, of the concentration camps, of the separation of children from their parents. Many countries developed a rich clinical culture, setting priorities that would not foster the development of formal research. Hence, it may not be by chance that the year 1952 not only saw HansJuergen Eysenck’s [4] powerful attack on the then prevailing psychoanalytic therapies but also listened to softer voices from the British psychoanalyst Edward Glover [5] pleading for formal research in psychoanalysis. The North American psychiatrist and psychoanalyst Lawrence Kubie [6] discussed problems and techniques of psychoanalytic validation in a first symposium on psychoanalysis as a science [7]. In post-war Germany, where the generation that had been trained during the Third Reich had to re-establish psychotherapy as a field, the early 1950s marked the move toward systematic research, mainly naturalistic. One of the very first German outcome studies was published by Annemarie Dührssen in 1953, reporting on ratings of therapists of a sample of patients treated at the Berlin Institute of Psychogenic Disorders [8]. At the Munich University policlinic, Cremerius [9] reported on over 600 cases that had been followed up for many years.1 One must appreciate the self-critical outcome study of the Norwegian psychoanalyst Harald Schjeldrup studying lasting effects of the psychoanalytic treatments he provided to his 28 patients before the German invasion had set an end to his clinical practice [10]. He had been professor and director at the Institute of Psychology since 1922. He realized that “a number of statistics on the results of psychoanalytic treatments have been published. But the figures do not provide an adequate basis for an assessment of the effectiveness of analytic therapy, either absolutely or in comparison with other forms of psychotherapy” [10]. Annemarie Dührssen reported on follow-up data on 1,004 patients [11]. These findings clearly contributed to the efforts to include psychoanalytic-oriented treatments of neurotic disturbances in

1

This study is even highly praised by Eysenck and Beech [13] for the relentless pursuit of long-term follow-up. xxi

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insurance coverage for the general population. Comparing the effectiveness and efficacy of the treatments to a control sample strengthened the case [12]. All but 15% of patients showed improvement, the largest group showing very considerable improvement maintained at follow-up. A substantial reduction in insurance claims for physical problems was associated with psychoanalytic treatment in the 5-year period following therapy. Though we can trace a few happy awakenings of psychotherapy research after the war in Europe as well, the appearance of the first edition of the Handbook of Psychotherapy and Behavior Change by Bergin and Garfield in 1971 confronted the European academic psychotherapy community with the striking fact that a field had developed with only one European representative as author of one of the chapters of the Handbook: HansJuergen Eysenck [13]. Trying to understand the European share in the new field, I went through the outcome chapter by Bergin [14]. The result of this search was a meager one: out of about 180 references, some 15 derive from European stock, British and continental: Fenichel’s [2] report was referred to in detail, also the aforementioned BMJ discussion from 1935 [3]; the various contributions by Eysenck, especially his negative but very seminal paper on “The Effects of Psychotherapy” [4], were cited. There were also some behavior therapists like Gelder and Marks [15] from the Maudsley Hospital on desensitization; Jonckheere [16], a Belgian colleague, from 1965 reporting on 72 neurotic patients treated with a variety of interventions; the Norwegian psychology professor Harald Schjelderup [10]; another Scandinavian named Kringlen [17] on longterm prognosis of obsessional neurosis; and just a little bit of David Malan, an unpublished manuscript from the year 1967. It did not cite the flagship study of Malan’s brief psychotherapy [18]. Bergin’s overview missed a few European references that marked the slow beginnings of European psychodynamic treatment research [9, 18–20]. When, after many battles, the University in Vienna opened the Institute for Depth Psychology and Psychotherapy in 1972, Hans Strotzka, as newly elected chair in his introductory lecture, pointed out that “in contrast to all other comparable countries, Austria is lacking nearly completely any effort to objectify the indications for psychotherapeutic treatments and the selection of adequate treatment methods. It lacks any effort to objectify the course of treatment and its outcome” [21]. Strotzka made the comparison to the medical practitioner who solely based on his own experience would select the appropriate antibiotics for his patients. He left no doubt that this situation would not be tolerated in somatic medicine and thus claimed that the field of psychotherapy could not continue to support the highly individualistic notions prevailing in Austrian psychotherapists’ minds. He strongly invoked the social responsibility to engage in empirical research [21]. In the same year at a meeting of the European psychoanalytic associations, he addressed the problem that the kind of patients treated in psychoanalysis cannot be referred to by reading the (I quote him) “excellent Handbook, especially the chapters by Garfield and by Luborsky. As cultural aspects are of high relevance, the validity of the American results has to be considered very restricted for central European populations”[22]. German populations were the object of a few naturalistic psychodynamic studies in the 1970s: the Heidelberg follow-up project [23, 24]; the Berlin study [25]; the Stuttgart follow-up study [26]. All these efforts were directed at evaluating the clinical reality; even the notion of a randomizedcontrolled experiment was not yet in researchers’ minds. This milestone for the development of formal psychodynamic research was provided by the first RCT comparing psychodynamic focal therapy to client-centered therapy conducted by A. E. Meyer at the Hamburg Collaborative Research Program [27]. The findings largely confirmed the equivalence of both kinds of treatment with small advantage for the client-centered modality. However, at the time of the 12-year follow-up, the differences were more salient in terms of matching of patients and therapists [28]. In Britain, the research group around David Shapiro in Sheffield had implemented a RCT comparing the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy [29]. Although they secured interesting differences of various dosages with respect to the severity of depression, they also became quite critical about the use of the drug-metaphor for psychotherapy [30].

Introduction, Part II

European Psychotherapy Research…

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A salient feature of European psychotherapy research is intricately tied up with the vast diversity of the service delivery systems. It may come as no surprise that generally the more northern countries in Europe (Scandinavian) have deployed more systematic efforts on psychotherapeutic care and its evaluation [31]. Specific turning points for the development of formalized psychodynamic psychotherapy research were the first international conference on Psychoanalytic Process Research Strategies in 1985 and the international meeting of the Society for Psychotherapy Research in Ulm in 1987. Research programs from a variety of European countries were presented demonstrating that one of the most frequent activities was process research [32]. Research on non-verbal interaction was much appreciated [33–35]. The development of psychodynamic psychotherapy research in the 1990s was characterized by a growing diversification of research approaches. Process-outcome research, large scale multi-site studies on the treatment of specific diseases, and health care system research became the leading paradigms [36]. Detailed process research on multiple cases combined with sophisticated outcome measurement became state of the art [37, 38]. Other studies focused on specific disorders like eating disorders [39] and Crohn’s disease [40]. The multi-center study on the psychodynamic treatment of eating disorders initiated by the Center for Psychotherapy Research in Stuttgart included a wide range of inpatient and outpatient modalities all over Germany [41]; it also was implemented in many European countries [42]. This study paradigmatically involved academics and non-university institutions, signaling a move to large-scale network operations. The present European situation is marked by a need to comply with the requirements of Evidence– Based Medicine. The meta-analysis by Grawe and his co-authors [43] ranking behavior therapy as the first line treatment and psychodynamic therapy as a second choice motivated intensive efforts of psychodynamic psychoanalytic researchers. The results of these recent efforts are documented in this volume.2 The future is always difficult to predict. The most recent developments are connected to what Ken Howard in 1987 termed consumer-oriented psychotherapy research. We need to understand the contingencies between patients’ needs and therapists’ competence in order to better serve these needs. It is obvious from the chapters in this volume that psychodynamic treatment research has made major advances in this direction. Horst Kächele, MD, PhD

References 1. Freud S. From the history on an infantile neurosis. SE vol XVII; 1918. pp 1–122. 2. Fenichel O. Statistischer Bericht über die therapeutische Tätigkeit 1920–1930. In: Radó S, Fenichel O, MüllerBraunschweig C, editors. Zehn Jahre Berliner Psychoanalytisches Institut. Poliklinik und Lehranstalt. Wien: Internationaler Psychoanalytischer Verlag; 1930. pp 13–19. 3. Luff MC, Garrod M. The after-results of psychotherapy in 500 adult cases. Brit Med J. 1935; 2: 54–59. 4. Eysenck HJ. The effects of psychotherapy: an evaluation. J Consult Psychol. 1952; 16: 319–324. 5. Glover E. Research methods in psycho-analysis. Int J Psychoanal. 1952; 33: 403–409. 6. Kubie LS. Problems and techniques of psychoanalytic validation and progress. In: Pumpian-Mindlin E, editor. Psychoanalysis as science. The Hixon lectures on the scientific status of psychoanalysis. New York: Basic Book; 1952. pp S 46–124. 7. Pumpian-Mindlin E, editor. Psychoanalysis as science. The Hixon lectures on the scientific status of psychoanalysis. New York: Basic Books; 1952. 8. Dührssen A. Katamnestische Untersuchungen bei Patienten nach analytischer Psychotherapie. Z Psychother Med Psychol. 1953; 3:167–170. 9. Cremerius J. Die Beurteilung des Behandlungserfolges in der Psychotherapie. Berlin: Springer; 1962. 10. Schjelderup H. Lasting effects of psychoanalytic treatments. Psychiatry. 1955; 18: 109–133. 2

Some of the chapters included here are based on presentations at the conference on Psychoanalytic Process Research Strategies III in Ulm, June 2009.

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11. Dührssen A. Katamnestische Ergebnisse bei 1004 Patienten nach analytischer Psychotherapie. Z Psychosom Med. 1962; 8: 94–113. 12. Dührssen AM, Jorswieck E. Eine empirisch-statistische Untersuchung zur Leistungsfähigkeit psychoanalytischer Behandlung. Nervenarzt. 1965; 36: 166–169. 13. Eysenck HJ, Beech HR. Counter conditioning and related methods. In: Bergin AE, Garfield SL, editors. Handbook of psychotherapy and behavior change. New York: Wiley; 1971. pp S 543–611. 14. Bergin A. The evaluation of therapeutic outcomes. In: Bergin AE, Garfield SL, editors. Handbook of psychotherapy and behavior change. New York: Wiley; 1971. pp S 217–270. 15. Gelder MG, Marks IM, Wolff HH. Desensitization and psychotherapy in the treatment of phobic states: a controlled inquiry. Br J Psychiatry. 1967; 113: 53–73. 16. Jonckheere P. Considerations sur la psychothérapie. Acta Neurologica et Psichiatrica Belgica. 1965; 65: 667–684. 17. Kringlen E. Obsessional neurosis: a long term follow up. Br J Psychiatry. 1965; 111: 709. 18. Malan DH. A study of brief psychotherapy. London: Tavistock; 1963. German version: Psychoanalytische Kurztherapie. Eine kritische Untersuchung. Bern/Stuttgart: Huber/Klett; 1965. 19. Beckmann D, Richter HE, Scheer JW. Kontrolle von Psychotherapieresultaten. Psyche. 1969; 23: 805–823. 20. Boor C de, Künzler E. Die psychosomatische Klinik und ihre Patienten. Stuttgart: Klett; 1963. 21. Strotzka H. Soziologische Kategorien psychoanalytischer Patienten. In: Strotzka H, editor. Neurose, Charakter und soziale Umwelt. Beiträge zu einer speziellen Neurosenlehre. Munich: Kindler Taschenbücher; 1973. pp 179–194 22. Strotzka H. Die soziale Verantwortung des Psychotherapeuten. In: Strotzka H, editor. Neurose, Charakter, soziale Umwelt. Kindler Taschenbücher, München: Kindler Taschenbuecher; 1973. Pp 203–214. 23. Kordy H, von Rad M, Senf W. Success and failure in psychotherapy: hypotheses and results from the Heidelberg follow-up project. Psychother Psychosom. 1983; 40: 211–227. 24. Kordy H, von Rad M, Senf W. Time and its relevance for a successful psychotherapy. Psychother Psychosom. 1988; 49: 212–222. 25. Rudolf G. Untersuchung und Befund bei Neurosen und Psychosomatischen Erkrankungen. Materalien zum Psychischen und Sozial- Kommunikativen Befund (PSKB). Basil: Beltz; 1981. 26. Göllner R, Volk W, Ermann M. Analyse von Behandlungsergebnissen eines zehn-jährigen Katamneseprogrammes. In: Beese F, editor. Stationäre Psychotherapie. Goettingen: Vandenhoeck & Rupprecht; 1978. 27. Meyer AE. The Hamburg short psychotherapy comparison experiment. Psychother Psychosom. 1981; 35: 77–220. 28. Meyer AE, Stuhr U, Wirth U, Rüster P. 12 year follow-up studies of the Hamburg short psychotherapy experiment. Psychother Psychosom. 1988; 50(4): 192–200. 29. Shapiro DA, Barkham M, Rees A, Hardy GE, Reynolds S, Startup M. Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol. 1994; 62: 522–534. 30. Shapiro DA, Harper H, Startup M, Reynolds S, Bird D, Suokas A. The high-watermark of the drug metaphor: a meta-analytic critique of process-outcome research. In: Russel RL, editor. Reassessing psychotherapy research. New York: Guilford; 1994. pp 1–35. 31. Kächele H, Pirmoradi S. Psychotherapy in European Public Mental Health Services. Int J Psychother. 2009; 13: 40 – 48. 32. Czogalik D. Interactional processes in psychotherapy. In: Beutler LE, Crago M, editors. Psychotherapy research: an international review of programatic studies. Washington: APA; 1991. pp 26–233. 33. Bänninger-Huber E. Prototypical affective microsequences in psychotherapeutic interaction. Psychother Res. 1992; 4: 291–306. 34. Krause R, Lütolf P. Facial indicators of transference processes within psychoanalytic treatment. In: Dahl H, Kächele H, Thomä H, editors): Psychoanalytic process research strategies. Berlin: Springer; 1988. pp 41–256. 35. Merten J, Ullrich B, Anstadt T, Buchheim P, Krause R. Experiencing of affects and facial behavior in the psychotherapeutic process and its relation to success. Psychother Res. 1996; 6: 198–212. 36. Kächele H, Kordy H. Outcome research. In: von Uexküll T, editor. Psychosom Med. New York: Urban & Schwarzenberg; 1993. 37. Strauß B. Empirische Untersuchungen zur stationären Gruppenpsychotherapie. Gruppenpsychother Gruppendyn. 1992; 28: 125–149. 38. Tschuschke V, Catina A, Beckh T, Salvini D. Wirkfaktoren in stationärer analytischer Gruppenpsychotherapie. Psychother Psychol Med. 1992; 42: 91–101. 39. Herzog W, Deter HC, Vandereycken W, editors. The course of eating disorders. Long-term follow-up studies of anorexia and bulimia nervosa. Berlin: Springer; 1992. 40. Wietersheim J von. Die Wirksamkeit von Psychotherapie aus der Sicht von M. Crohn-Patienten. Ergebnisse einer multizentrischen Studie. Frankfurt: VAS-Verlag für akademische Schriften; 1999. 41. Kächele H, Kordy H, Richard M, Studiengruppe MZ-ESS. Therapy amount and outcome of inpatient psychodynamic psychotherapy of eating disorders. Results of a multi center study across Germany. Psychother Res. 2001; 11: 239–257. 42. Kordy H, Krämer B, Palmer RJ, Papezova H, Pellet J, Richard M, Treasure J, COST Action B6. Remission, recovery, relapse, and recurrence in eating disorders: conceptualization and illustration of a validation strategy. J Clin Psychol. 2002; 58: 833–846. 43. Grawe K. Psychotherapieforschung zu Beginn der neunziger Jahre. Psychol Rundschau. 1992; 43: 132–162.

Contents

Part I

Outcome Research

1 Commentary: Research on Short- and Long-Term Psychoanalytic Treatment – The Current State of the Art ......................................... Jeremy D. Safran and Alexandra G. Shaker 2 The Efficacy of Psychodynamic Psychotherapy ............................................................ Jonathan Shedler 3 Effectiveness of Long-Term Psychodynamic Psychotherapy: First Meta-Analytic Evidence and Its Discussion ......................................................... Sven Rabung and Falk Leichsenring 4 Must All Have Prizes? The Munich Psychotherapy Study .......................................... Dorothea Huber, Gerhard Henrich, Judith Gastner, and Guenther Klug 5 The Helsinki Psychotherapy Study: Effectiveness, Sufficiency, and Suitability of Short- and Long-Term Psychotherapy ........................................... Paul Knekt, Maarit A. Laaksonen, Tommi Härkänen, Timo Maljanen, Erkki Heinonen, Esa Virtala, and Olavi Lindfors

3 9

27 51

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6 Psychoanalytic and Psychodynamic Therapies for Depression: The Evidence Base ........................................................................................................... David Taylor

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7 Evidence-Based Psychodynamic Treatments for Anxiety Disorders: A Review ........................................................................................................................... Jenelle Slavin-Mulford and Mark J. Hilsenroth

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8 An Update and Overview of the Empirical Evidence for Transference-Focused Psychotherapy and Other Psychotherapies for Borderline Personality Disorder ............................................................................... Kenneth N. Levy, Kevin B. Meehan, and Frank E. Yeomans 9 What Happens After Treatment: Can Structural Change be a Predictor of Long-Term Outcome? ................................................................................ Tilman Grande, Wolfram Keller, and Gerd Rudolf

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Part II

Contents

The Neurobiology of Psychotherapy

10 Commentary: Neurobiology of Psychotherapy – State of the Art and Future Directions ............................................................................................... Andrew J. Gerber

187

11 Neural Models of Psychodynamic Concepts and Treatments: Implications for Psychodynamic Psychotherapy .......................................................... Joshua L. Roffman, Andrew J. Gerber, and Debra M. Glick

193

12 Toward Molecular Psychotherapy of Depression?........................................................ Johannes Lehtonen, Jari Tiihonen, Mikko Martti Oskari Joensuu, Soili M. Lehto, Pasi Olavi Ahola, Pirjo Irmeli Saarinen, Minna Valkonen-Korhonen, Tommi Tolmunen, and JyrkiT. Kuikka 13 Psychotherapy Increases the Amount of Serotonin Receptors in the Brains of Patients with Major Depressive Disorder........................................... Hasse Karlsson 14 Neural Correlates of Emotion, Cognition, and Attachment in Borderline Personality Disorder and Its Clinical Implications ................................... Anna Buchheim, Roberto Viviani, Carol George, Horst Kächele, and Henrik Walter 15 Neurobiologically Informed Psychotherapy of Borderline Personality Disorder ..................................................................................... Glen O. Gabbard 16 Foundations of Psychodynamic Therapy: Implicit Emotional Learning ................... Philip S. Wong and Dana M. Haywood 17 Neurobiological Correlates of the Psychotherapy Relationship and E.M.P.A.T.H.Y.: The Role of Biomarkers in Psychotherapy ................................ Helen Riess 18 Bridging Technology and Psychotherapy: Toward Investigating Psychological and Neural Correlates of Psychodynamic Psychotherapy ................... Sharmin Ghaznavi, Janet M. Witte, Raymond A. Levy, and Joshua L. Roffman 19 The Neurobiological Foundations of Psychotherapy .................................................... George I. Viamontes Part III

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Theory, Technique, and Process

20 Commentary: The Coming of Age of Psychoanalytic Treatment Research ......................................................................................................... Patrick Luyten

337

21 Process and Outcome in Psychoanalytic Psychotherapy Research: The Need for a (Relatively) New Paradigm ................................................................... Patrick Luyten, Sidney J. Blatt, and Linda C. Mayes

345

22 How to Make Practical Use of Therapeutic Alliance Research in Your Clinical Work ...................................................................................................... Mark J. Hilsenroth, Thomas D. Cromer, and Steven J. Ackerman

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23 The Contributions of the Psychotherapy Process Q-set to Psychotherapy Research ............................................................................................. Lotte Smith-Hansen, Raymond A. Levy, Carolina Seybert, Ingrid Erhardt, and J. Stuart Ablon 24 Attachment Theory and Research: Implications for Psychodynamic Psychotherapy....................................................................................... Kenneth N. Levy, Kevin B. Meehan, Christina M. Temes, and Frank E. Yeomans 25 Accuracy of Defense Interpretation in Three Character Types................................... J. Christopher Perry, Jonathan Petraglia, Trevor R. Olson, Michelle D. Presniak, and Jesse A. Metzger 26 When Is Transference Work Useful in Psychodynamic Psychotherapy? A Review of Empirical Research .................................................................................... Per Høglend and Glen O. Gabbard Part IV

401 417

449

Single Case Studies

27 Single-Case Research: The German Specimen Case Amalia X ................................... Horst Kächele, Joseph Schachter, and Helmut Thomä 28 Combining Idiographic and Nomothetic Approaches to Single-Case Research ....................................................................................................... Tai Katzenstein, Nnamdi Pole, J. Stuart Ablon, and Carrie Olsen 29 A Session of Psychoanalysis as Analyzed by the Psychotherapy Process Q-set: Amalia X, Session 152 ............................................................................ Raymond A. Levy, J. Stuart Ablon, Helmut Thomä, Horst Kächele, Julie Ackerman, Ingrid Erhardt, and Carolina Seybert Part V

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Assessing Change

30 Ten Diverse Outcome Measures for Psychodynamic Psychotherapy Research ................................................................................................. Caleb J. Siefert and Jared A. DeFife 31 Empirically Informed Clinical Interviewing for Personality Disorders ..................... Jared A. DeFife and Drew Westen 32 The Structured Interview of Personality Organization (STIPO): An Instrument to Assess Severity and Change of Personality Pathology ................... Susanne Hörz, John F. Clarkin, Barry L. Stern, and Eve Caligor

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Appendices Appendix IA Psychotherapy Process Q-Set Coding Manual (Adult) .............................. Originally Developed by Enrico E. Jones and Revised Herewith by the Psychotherapy Research Program at Massachusetts General Hospital (J. Stuart Ablon, Raymond A. Levy, John M. Kelley, Ira Lable, Helen Riess, Robert S. Abernethy III, Jeremy P. Nahum, Carolina Seybert, Ingrid Erhardt, Julie Ackerman)

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Appendix IB Child Psychotherapy Q-Set Coding Manual ............................................... Celeste Schneider and Enrico E. Jones Appendix IIA Introduction to Manualized Treatments for Psychodynamic Psychotherapy Research ........................................................................ Carolina Seybert, Ingrid Erhardt, Raymond A. Levy, and Horst Kächele

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Appendix IIB Listing of Psychodynamic Manualized Treatments................................... Compiled by Carolina Seybert, Ingrid Erhardt, Raymond A. Levy, and Horst Kächele

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Index ..........................................................................................................................................

635

Contributors

Robert S. Abernethy III Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA J. Stuart Ablon Department of Psychiatry, Harvard Medical School, Boston, MA, USA Psychotherapy Research Program, Massachusetts General Hospital, Boston, MA, USA Julie Ackerman Clinical Psychology Program, City University of New York, New York, NY, USA Steven J. Ackerman Erik H. Erikson Institute for Research, The Austen Riggs Center, Stockbridge, MA, USA Pasi Olavi Ahola Department of Psychiatry, University of Eastern Finland, University Hospital of Kuopio, Kuopio, Finland Sidney J. Blatt Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA Anna Buchheim Department of Psychology, University of Innsbruck, Innsbruck, Austria Eve Caligor Department of Psychiatry, New York University School of Medicine, New York, NY, USA John F. Clarkin Department of Psychiatry, Weill Cornell Medical College, White Plains, NY, USA Thomas D. Cromer Department of Psychiatry, North Shore University Hospital, Manhasset, NY, USA Jared A. DeFife Department of Psychology, Emory University, Atlanta, GA, USA Ingrid Erhardt Department of Pediatric Psychosomatic Medicine and Psychotherapy, Dr. Von Hauner’s Children’s Hospital, Munich, Germany Glen O. Gabbard Professor of Psychiatry, Suny Upstate Medical University, Syracuse, NY, USA Clinical Professor of Psychiatry, Baylor College of Medicine, Houston, TX, USA Judith Gastner Department of Psychosomatic Medicine and Psychotherapy, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany Carol George Department of Psychology, Mills College, Oakland, CA, USA

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Andrew J. Gerber Division of Child and Adolescent Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY, USA Sharmin Ghaznavi Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Debra M. Glick Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Tilman Grande Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany Tommi Härkänen Department of Health, Functional Capacity, and Welfare, National Institute for Health and Welfare, Helsinki, Finland Dana M. Haywood PhD Program in Clinical Psychology, Department of Psychology, Long Island University, Brooklyn, NY, USA Erkki Heinonen Department of Health, Functional Capacity, and Welfare, National Institute for Health and Welfare, Helsinki, Finland Gerhard Henrich Department of Psychosomatic Medicine and Psychotherapy, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany Mark J. Hilsenroth Derner Institute of Advanced Psychological Studies, Adelphi University, Garden City, NY, USA Susanne Hörz Department of Psychology, Ludwig-Maximilians University, Munich, Germany Per Høglend Institute of Clinical Medicine, University of Oslo, Oslo, Norway Dorothea Huber Department of Clinical Psychology and Psychosomatics, International Psychoanalytic University, Berlin, Germany Clinic for Psychosomatic Medicine and Psychotherapy, Klinikum Harlaching, Munich, Germany Mikko Martti Oskari Joensuu Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland Enrico E. Jones University of California, Berkeley, Berkeley, CA, USA Horst Kächele Department of Clinical Psychology and Psychoanalysis, International Psychoanalytic University, Berlin, Germany Hasse Karlsson Department of Clinical Medicine, University of Turku, Turku, Finland Tai Katzenstein Department of Psychiatry, Harvard Medical School, Boston, MA, USA Wolfram Keller Head of the Department of Psychosomatics, Kliniken im Theodor-Wenzel-Werk, Berlin, Germany John M. Kelley Department of Psychology, Endicott College, Harvard Medical School, Massachusetts General Hospital, Beverly, MA, USA Guenther Klug Department of Psychosomatic Medicine and Psychotherapy, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany Paul Knekt Department of Health, Functional Capacity, and Welfare, National Institute for Health and Welfare, Helsinki, Finland Jyrki T. Kuikka Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland

Contributors

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Maarit A. Laaksonen Department of Health, Functional Capacity, and Welfare, National Institute for Health and Welfare, Helsinki, Finland Ira Lable Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Soili M. Lehto Department of Psychiatry, University of Eastern Finland, University Hospital of Kuopio, Kuopio, Finland Johannes Lehtonen Department of Psychiatry, University of Eastern Finland, University Hospital of Kuopio, Kuopio, Finland Falk Leichsenring Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany Kenneth N. Levy Department of Psychology, Pennsylvania State University, University Park, PA, USA Raymond A. Levy Department of Psychiatry, Harvard Medical School, Psychotherapy Research Program, Massachusetts General Hospital, Boston, MA, USA Olavi Lindfors Department of Health, Functional Capacity, and Welfare, National Institute for Health and Welfare, Helsinki, Finland Patrick Luyten Department of Psychology, University of Leuven, Leuven, Belgium Research Department of Clinical, Educational and Health Psychology, University College London, London, UK Timo Maljanen Research Department, The Social Insurance Institution of Finland, Helsinki, Finland Linda C. Mayes Yale Child Study Center, Yale University, New Haven, CT, USA Kevin B. Meehan Department of Psychology, Long Island University, Brooklyn, NY, USA Jesse A. Metzger McGill University at the Institute of Community and Family Psychiatry, SMBD Jewish General Hospital, Montreal, QC, Canada Jeremy P. Nahum Department of Psychiatry, Harvard Medical School, West Newton, MA, USA Carrie Olsen Department of Psychology, Smith College, Northampton, MA, USA Trevor R. Olson FIT for Active Living, Saskatoon City Hospital, Saskatoon, SK, Canada J. Christopher Perry McGill University at SMBD Jewish General Hospital, Montreal, QC, Canada Jonathan Petraglia Department of Counseling Psychology, McGill University, Montreal, QC, Canada Nnamdi Pole Department of Psychology, Smith College, Northampton, MA, USA Michelle D. Presniak FIT for Active Living, Saskatoon City Hospital, Saskatoon, SK, Canada Sven Rabung Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Department of Psychology, University of Klagenfurt, Austria Helen Riess Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

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Contributors

Joshua L. Roffman Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA Gerd Rudolf Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany Pirjo Irmeli Saarinen Department of Psychiatry, University of Eastern Finland, University Hospital of Kuopio, Kupio, Finland Jeremy D. Safran Department of Psychology, New School for Social Research, New York, NY, USA Joseph Schachter Columbia University Center for Psychoanalytic Training and Research, New York, NY, USA Celeste Schneider San Francisco Center for Psychoanalysis, San Francisco, CA, USA Carolina Seybert Department of Psychosomatic Medicine and Psychotherapy, University of Ulm, Ulm, Germany Alexandra G. Shaker Department of Psychology, New School for Social Research, New York, NY, USA Jonathan Shedler Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA Caleb J. Siefert Department of Psychology, University of Michigan—Dearborn, Dearborn, MI, USA Jenelle Slavin-Mulford Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Lotte Smith-Hansen Program for Psychotherapy, Cambridge Health Alliance, Cambridge, MA, USA Barry L. Stern Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA David Taylor Adult Department, Tavistock Clinic, Tavistock & Portman NHS Foundation Trust, London, United Kingdom Christina M. Temes Department of Psychology, Pennsylvania State University, University Park, PA, USA Helmut Thomä Department of Psychotherapy at the University of Ulm, Ulm, Germany Jari Tiihonen Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland Tommi Tolmunen Department of Adolescent Psychiatry, Kuopio University Hospital, Kuopio, Finland Minna Valkonen-Korhonen Department of Psychiatry, University of Eastern Finland, Kuopio, Finland George I. Viamontes OptumHealth Behavioral Solutions, St. Louis, MO, USA Esa Virtala Department of Health, Functional Capacity, and Welfare, National Institute for Health and Welfare, Helsinki, Finland

Contributors

Roberto Viviani Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, Germany Henrik Walter Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin, Berlin, Germany Drew Westen Departments of Psychology and Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA Janet M. Witte Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Philip S. Wong PhD Program in Clinical Psychology, Department of Psychology, Long Island University, Brooklyn, NY, USA Frank E. Yeomans Department of Psychiatry, Weill Medical College of Cornell University, New York, NY, USA

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Part I

Outcome Research

Chapter 1

Commentary: Research on Short- and Long-Term Psychoanalytic Treatment – The Current State of the Art Jeremy D. Safran and Alexandra G. Shaker

Keywords Psychoanalytic Treatment • Outcome Research • Empirical Evidence • Evidence Based psychoanalysis It is a great pleasure to have the opportunity to read and comment on the chapters in this section. Some of the chapters provide superb summaries and updates on innovative psychoanalytic research programs. Others provide comprehensive reviews of the research on the psychoanalytic treatment of specific disorders. Together, they constitute an immensely satisfying summary of state-of-the-art research findings on psychoanalytic process and outcome. The section begins with Jonathan Shedler’s already classic American Psychologist article on the efficacy of psychodynamic therapy (Chap. 2). This masterfully written chapter summarizes the results of eight meta-analytic reviews of the research on the efficacy of psychodynamic therapy and concludes that the effects sizes for psychodynamic treatments are as large as those reported for other therapies that have been promoted as empirically supported, including cognitive-behavioral therapy. He also concludes that the evidence indicates that patients receiving psychodynamic treatment maintain therapeutic gains. Moreover, existing evidence suggests that these gains continue to increase after treatment ends. Shedler also reviews some of the more promising research on the efficacy of psychoanalytically oriented treatments of borderline personality (a more in-depth and extensive review of this research can be found in Chap. 8). While none of the research reviewed in this chapter is new, Shedler has made a tremendously important contribution to the field by summarizing it all in one place, and by demonstrating the skill and persistence necessary to navigate his way through what we happen to know was a rather rigorous and arduous review process, likely to have been influenced by the fact that his conclusions challenge the accepted/received view. The compelling narrative constructed by Shedler, in combination with the widely read nature of American Psychologist, have already led to widespread attention and stirred up considerable controversy. Shedler’s chapter is followed by Rabung and Leichsenring’s chapter (Chap. 3) that includes a review of their widely cited Journal of the American Medical Association (JAMA) meta-analysis on studies of long-term psychodynamic therapy (LTPP) [1], followed by a review of various critiques of their meta-analysis published in the form of letters submitted to JAMA, and their responses to them. The original meta-analysis included 11 RCT studies and 12 quasi-experimental studies. All patients in the studies were diagnosed with either personality disorders or chronic and/or multiple mental disorders. Their rationale for including only studies with patients meeting these criteria was

J.D. Safran (*) • A.G. Shaker Department of Psychology, New School for Social Research, New York, NY, USA e-mail: [email protected]; [email protected] R.A. Levy et al. (eds.), Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence, Current Clinical Psychiatry, DOI 10.1007/978-1-60761-792-1_1, © Springer Science+Business Media, LLC 2012

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that it is precisely for this particular population that longer-term psychodynamic treatment is likely to be indicated (as opposed to less difficult or chronic cases that may benefit from short-term treatment). They concluded that the studies included in their review showed large and significant effect sizes across a wide spectrum of outcome domains and that LTPP is both effective and superior to less intensive or shorter-term therapies for this patient population. This is the first time the critiques of the original JAMA meta-analysis and the authors’ responses to them have all been assembled in one place, and the final product makes for compelling reading. Since both sides of this controversy are well detailed in the Rabung and Leichsenring chapter, we leave it to the reader to review the chapter carefully and draw his or her own conclusions. We would, however, like to commend Rabung and Leichsenring for their careful consideration of the critiques and their careful, thorough, and well-reasoned responses to them. In an era when the prevailing wisdom tends to be that short-term treatments are appropriate for all conditions and that longer-term treatment is neither necessary nor cost effective, the compelling results of the meta-analysis described in Rabung and Leichsenring’s chapter as well as their response to their critics are particularly timely. It is important to bear in mind, however, that the studies included in it are “long term” relative to the majority of treatments included in randomized clinical trials. Treatments of the duration and intensity of the studies included in this meta-analysis may well be closer to the norm to many treatments conducted in the real world (e.g., see Westen and colleagues [2]) than the type of short-term therapy typically studied in randomized clinical trials. But what about longer-term, intensive, psychoanalytic treatment? Because of the logistical and methodological problems associated with studying this type of treatment, it is rare to find studies that are not naturalistic in nature or that have reliable measures administered at intake, termination, and follow-up intervals. The next two chapters summarize important attempts to fill this niche. The Huber et al. (Chap. 4) is a unique contribution to the literature providing one of the most compelling sources of evidence to date that long-term psychoanalysis has unique benefits. Although both Seligman’s [3] effectiveness study and Howard et al.’s [4] research on the dose–effect response provide some evidence that longer-term treatments offer advantages over short-term treatments, the methodological difficulties associated with evaluating the relative effectiveness of long-term intensive psychoanalytic treatment versus shorter-term, less intensive treatments (either psychodynamic or cognitive-behavioral) are extremely difficult to overcome. The practical difficulties associated with use of a randomized clinical trial in this context are virtually insurmountable. By using a quasiexperimental design, however, which balances considerations of internal validity and external validity, Huber et al. are able to provide credible evidence not only for the unique benefits of longer-term, intensive psychoanalytic treatment over shorter-term, less intensive treatment (both psychodynamic and cognitive-behavioral), but also for the benefits of psychodynamic treatment over cognitivebehavioral treatment of equivalent intensity and duration. Since the Munich Psychotherapy Study is still a work in progress, data from the 3-year follow-up interval are not in yet. Future research in this vein will also need to address concerns raised by critics (e.g., the lack of adherence ratings, questions about what can and cannot be inferred from this type of quasi-experimental design). Nevertheless, we do see the Munich Psychotherapy Study as an important and innovative step forward. Moreover, it is our understanding that Huber et al. are now conducting process ratings to determine both adherence and the active ingredients of the treatments. Once completed, these rating have the potential of further enhancing both the rigor and implications of their research. The Knekt et al. (Chap. 5) reports on the results of an ambitious, methodologically complex study that is still in progress. It combines a randomized clinical trial of three different treatment modalities: solution-focused therapy (SFT), short-term psychodynamic psychotherapy (STPP), and longterm psychodynamic psychotherapy (LTPP). The study also has an additional arm comparing a group of patients self-selected for long-term open-ended psychoanalysis. The complexity of the methodology extends beyond the addition of the nonrandomly assigned psychoanalytic arm. In addition, there are differences in the intensity and length of the SFT (one every 2 weeks for 12 sessions),

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STPP (once a week for 20 sessions), LTPP (2–3 times per week for approximately 3 years), and PA (sessions four times per week for approximately 5 years). The plan is to follow patients for a 10-year interval. At present, they have data from the 5-year follow-up period. Because of the various methodological confounds associated with the study, findings inevitably need to be interpreted cautiously. Bearing this in mind, however, the chapter reports a number of interesting preliminary findings. At the time of the first year follow-up, patients in STPP had greater improvement in their psychiatric symptoms than those in the LTPP group, and patients in SFT had greater improvement in their symptoms of depression than those in the LTPP group. At the 3-year follow-up, the findings were opposite, and those in the LTPP group had a stronger treatment effect than those in the two short-term conditions, with regard to symptoms of both depression and anxiety. On one hand, these findings can be interpreted as evidence of the advantages of LTPP over STPP and SFT. On the other, however, given the confound of treatment duration with treatment intensity, in addition to the fact that it appears that patients were terminating the LTPP condition at around the time of the 3-year follow-up (as opposed to patients in the other conditions who had terminated treatment over 2 years ago), it is difficult to know quite how to interpret the findings. Knekt et al. also report that, at the end of the 5-year follow-up interval, the symptom levels in the psychoanalysis group were lower than in the long-term psychotherapy group. Again, however, the various confounds already mentioned make it difficult to interpret these findings. At the 10-year follow-up interval, it will be somewhat easier to interpret the meaning of differences emerging between treatment modalities. Notwithstanding the various methodological confounds intrinsic to this study, Knekt et al. are collecting an extremely rich data set that is likely to yield a variety of suggestive findings over time regarding such issues as cost-effectiveness, treatment sufficiency (i.e., is the treatment meeting the needs of the patient or are they seeking additional treatment with medication, etc.), patient suitability for different modalities, and the feasibility and value of using certain types of quasi-controlled psychotherapy research methodologies in real-world settings. Taylor (Chap. 6) reviews a number of different studies and meta-analyses (some also reviewed in other chapters in this book) that evaluate the effectiveness of either short-term or longer-term psychodynamic treatment for depression. On the basis of the literature reviewed, he concludes that the effects sizes for short-term psychodynamic treatments for depression are similar to those of other forms of psychotherapy. He also concludes that the effects of cognitive-behavioral treatments may be evident more rapidly than those of psychodynamic treatments and that patients receiving longerterm psychoanalytic treatment may result in qualitatively different types of changes than short-term treatments. These qualitatively different types of changes (presumably the type of structural change investigated by Grande et al. in Chap. 9) may play an important role in relapse prevention. Taylor’s chapter also reflects on the limitations of many of the assumptions and features dominating the prevailing research paradigm (e.g., the discrete nature of diagnostic categories, the reliance on randomized clinical trials as the “gold standard” of research (or what he refers to as the “guardian of truth”)), the failure to use outcome measures that assess more subtle and meaningful dimensions of change, the failure to take into account the chronic and recurrent nature of depression, and the bias towards viewing short-term treatment as more adequate than in fact it may be for a variety of problems. Slavin-Mulford and Hilsenroth’s (Chap. 7) reviews a number of important studies on psychodynamic treatments for anxiety disorders. To our knowledge, this is the first review of psychodynamic treatments for anxiety disorders that has been published. They discuss research that examines both the efficacy and effectiveness of psychodynamic therapy for anxiety disorders. In presenting the findings of Pierloot and Vinck [5] and Brom et al. [6], Slavin-Mulford and Hilsenroth argue that one distinction between cognitive and behavioral treatments and psychodynamic treatments in the context of anxiety disorders is that it may be that after therapy has terminated, those who receive psychodynamic treatment will continue to make therapeutic gains, whereas those who have received cognitive and behavioral treatments may experience rapid symptom reduction during the initial stages of treatment, but their gains may diminish following termination.

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Slavin-Mulford and Hilsenroth discuss the importance of both efficacy and effectiveness studies in order to achieve internal and external validity in treatment research. Their review of Crits-Cristoph and colleagues’ 1996 and 2005 studies [7, 8] and Milrod and colleagues’ 2000 and 2001 studies [9, 10] presents highly compelling evidence for the effectiveness of psychodynamic treatments for anxiety disorders. In this chapter, Slavin-Mulford and Hilsenroth call attention to the limited nature of any research methodology and the need for a range of approaches in treatment studies. While the research presented in this chapter demonstrates mixed findings with regard to psychodynamic treatment for anxiety disorders, the authors present a number of studies conducted in a range of settings, emphasizing the various contributions to the field that different research methodologies can bring to the table. Levy et al. (Chap. 8) provide a superb review of the research on psychoanalytically oriented treatments for borderline personality disorder (BPD). Studies in this area, while still limited in number, are some of the most promising in the field. For many years, the received wisdom was that dialectical behavior therapy was the only treatment for BPD with any form of empirical backing. Given the serious nature of this disorder, the difficulties and anxieties that clinicians commonly experience when treating BPD patients, and the cost to the health care system, DBT has become widely disseminated and immensely popular in the field. In this chapter, Levy et al. review their own groundbreaking research on Kernberg’s transference-focused therapy (TFP) [11, 12], and Bateman and Fonagy’s [13] highly promising study regarding the effectiveness of mentalization-based therapy and long-term stability of changes resulting from it. They also provide cogent critiques of the GiesenBloo et al. [14] study demonstrating the superiority of schema-focused therapy to TFP. In addition, they review the recently published Doering et al. [15] RCT, which provides independent corroboration of the efficacy of TFP for BPD. Finally, they review the recently published RCT by McMain et al. [16] that compared DBT to a general psychiatric management based on the American Psychiatric Treatment Guidelines, which combined a psychodynamic individual psychotherapy (based on Gunderson’s [17] model of treatment), with pharmacotherapy and case management. This study found no significant differences between the two treatment conditions across a wide spectrum of dimensions. The finding of therapeutic equivalence in the McMain et al. [16] study is particularly noteworthy given the fact that McMain is a DBT proponent (given the important impact of researcher theoretical allegiance on outcome) [18]. A noteworthy finding in the Levy et al. study [19] reviewed in this chapter is the finding that, while at termination, patients receiving DBT showed equivalent changes to those receiving TFP, only patients in the TFP positions showed changes in both reflective functioning and attachment status (as assessed by the Adult Attachment Interview). Both of these measures can be conceptualized as indices of internal representations or internal structure. It will be important to see whether changes in attachment status and reflective functioning have implications for the sustainability of treatment effects at follow-up. This brings us to the closing chapter in the section by Grande et al. (Chap. 9), which summarizes their innovative efforts to investigate and document the impact of structural change in psychoanalytic treatment. While psychoanalysts have long argued that one of the important goals of treatment consists of change in psychic structure, until now there, has been little if any empirical evidence for this assertion. A number of obstacles have traditionally hindered research in this area. One is a lack of agreement about what we mean by psychic structure. Another related problem is the difficulty of operationalizing the construct. Finally, it is difficult to document the value of structural change. Given the consistent finding of “therapeutic equivalence” in psychotherapy outcome research, it becomes particularly important not only to verify that structural change does take place but also that such change is valuable. The development of the Heidelberg Structural Changes Scale (HSCS) provides an innovative method for measuring structural change in a way that is meaningful across a range of diverse psychoanalytic perspectives. Grande et al.’s finding that structural change at termination (as assessed by the HSCS) is predictive of patients’ retrospective evaluations of treatment success, at the 3-year

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follow-up point, while symptom change is not, provides compelling evidence of the meaningfulness of the construct of psychic change. It also provides evidence that change in psychic structure is a goal worth aspiring to in tangible terms that therapists across diverse theoretical traditions should be able to agree upon. While acknowledging the limitations of assessing change retrospectively (at the 3-year follow-up point), in our opinion, the authors do make a plausible case for the value of such retrospective evaluations. Important future directions for research will include [1] evaluating change at follow-up using pre–post assessments, and [2] evaluating whether different treatment modalities have different impacts on changes at this level. Collectively, the chapters in this section provide an important review of state-of-the-art research on the effectiveness of both short-term and long-term psychoanalytically oriented treatment for a variety of disorders. They summarize promising evidence regarding the effectiveness of these treatment modalities and highlight limitations in the research. They also spell out methodological problems that bedevil the field and that make it difficult to study longer-term psychoanalytic treatments in particular. They also provide a glimpse of innovative attempts to grapple with some of these problems and of promising research avenues for the future. One of the more promising findings discussed in a number of the chapters is the evidence beginning to emerge that the gains of psychoanalytically oriented treatment may actually continue to increase after termination. Findings of this type are consistent with the hypothesis that helpful psychoanalytically oriented treatment leads to underlying structural change, which may serve a relapse prevention function and actually facilitate continuing change after treatment. This hypothesis is directly tested in the innovative research reported in the chapters by both Levy et al. and Grand et al. (Chaps. 8 and 9). Another consistent theme that is beginning to emerge is that patients in cognitive-behavioral treatments are likely to experience symptom reduction earlier in the treatment process than patients in psychoanalytically oriented treatments, but this pattern is likely to disappear and in some cases even reverse itself in psychoanalytically oriented treatments. Finally, while acknowledging the methodological difficulties associated with conducting research on long-term, intensive psychoanalytic treatment, a number of these chapters provide some of the most promising evidence to date regarding the unique value of this treatment modality. We would like to close by expressing our appreciation to the contributors for their important contributions, and to J. Stuart Ablon, Ray Levy Horst Kächele for soliciting and assembling these important contributions and inviting us to provide a commentary.

References 1. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta—analysis. J Am Med Assoc. 2008;300(13):1551–65. 2. Westen D, Novotny CM, Thompson-Brenner H. The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. Psychol Bull. 2004;130:631–63. 3. Seligman MEP. The effectiveness of psychotherapy: the consumer reports study. Am Psychol. 1995;50:965–74. 4. Howard KI, Kopta SM, Krause MS, Orlinsky DE. The dose-effect relationship in psychotherapy. Am Psychol. 1986;41:159–64. 5. Pierloot R, Vinck J. Differential outcome of short-term dynamic psychotherapy and systematic desensitization in the treatment of anxious out-patients: a preliminary report. Psychol Belg. 1978;18(1):87–98. 6. Brom D, Kleber RJ, Defares PB. Brief psychotherapy for posttraumatic stress disorders. J Consult Clin Psychol. 1989;57(5):607–12. 7. Crits-Cristoph P, Connolly MB, Azarian K, Crits-Cristoph K, Shappell S. An open trial of brief supportiveexperssive psychotherapy in the treatment of generalized anxiety disorder. Psychother-Theory Res. 1996;33(3):418–30. 8. Crits-Cristoph P, Connolly Gibbons MB, Narducci J, Schamberger M, Gallop R. Interpersonal problems and the outcome of interpersonally oriented psychodynamic treatment of GAD. Psychother-Theory Res. 2005;42:211–23.

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9. Milrod B, Busch F, Leon AC, Shapiro T, Aronson A, Roiphe J, et al. Open trial of psychodynamic psychotherapy for panic disorder: a pilot study. Am J Psychiatry. 2000;157(11):1878–80. 10. Milrod B, Busch F, Leon AC, Aronson A, Roiphe J, Rudden M, et al. A pilot trial of brief psychodynamic psychotherapy for panic disorder. J Psychother Pract Res. 2001;10:239–45. 11. Clarkin JF, Yeomans FE, Kernberg OF. Psychotherapy for borderline personality. New York: Wiley; 1999. 12. Clarkin JF, Yeomans F, Kernberg OF. Psychotherapy of borderline personality. New York: Wiley; 2006. 13. Bateman AW, Fonagy P. Mentalization-based treatment of BPD. J Pers Disord. 2004;18(1):36–51. 14. Giesen-Bloo JH, Arntz A, van Dyck R, Spinhoven P, Van Tilburg W, Dirksen C, Van A, et al. Outpatient psychotherapy for borderline personality disorder: a randomized clinical trial of schema focused therapy versus transference focused psychotherapy. Arch Gen Psychiatry. 2006;63:649–58. 15. Doering S, Hörz S, Rentrop M, Fischer-Kern M, Schuster P, Benecke C, Buchheim A, Martius P, Buchheim P. Transference-Focused psychotherapy vs. treatment by community psychotherapists for borderline personality disorder: a randomized controlled trial. Br J Psychiatry. 2010;196:389–95. 16. McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiat. 2009;166:1365–74. 17. Gunderson JG. Borderline personality disorder: a clinical guide. Washington, DC: American Psychiatric; 2006. 18. Luborsky L, Barrett MS. Theoretical allegiance. In: Norcross JC, Beutler LE, Levant RF, editors. Evidence based practices in mental health. Washington, DC: American Psychological Association; 2006. 19. Levy KN, Clarkin JF, Kernberg OF. Change in attachment and reflective function in the treatment of borderline personality disorder with transference focused psychotherapy. J Consult Clin Psychol. 2006;74:1027–40.

Chapter 2

The Efficacy of Psychodynamic Psychotherapy * Jonathan Shedler

Keywords Meta-analysis • Psychoanalysis • Psychodynamic psychotherapy • Psychotherapy outcome • Psychotherapy process

There is a belief in some quarters that psychodynamic concepts and treatments lack empirical support, or that scientific evidence shows that other forms of treatment are more effective. The belief appears to have taken on a life of its own. Academicians repeat it to one another, as do healthcare administrators, as do healthcare policy makers. With each repetition, its apparent credibility grows. At some point, there seems little need to question or revisit it because “everyone” knows it to be so. The scientific evidence tells a different story: considerable research supports the efficacy and effectiveness of psychodynamic psychotherapy. The discrepancy between perceptions and evidence may be due, in part, to biases in the dissemination of research findings. One potential source of bias is a lingering distaste in the mental health professions for past psychoanalytic arrogance and authority. In decades past, American psychoanalysis was dominated by a hierarchical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research. This did not win friends in academic circles. When empirical findings emerged that supported nonpsychodynamic treatments, many academicians greeted them enthusiastically and were eager to discuss and disseminate them. When empirical evidence supported psychodynamic concepts and treatments, it was often overlooked.

*

Copyright © 2010 by the American Psychological Association. Reproduced with permission. The official citation that should be used in referencing this material is Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65(2):98–109. No further reproduction or distribution is permitted without written permission from the American Psychological Association. The author thanks Mark Hilsenroth for his extensive contributions to this chapter; Marc Diener for providing some of the information reported here; and Robert Feinstein, Glen Gabbard, Michael Karson, Kenneth Levy, Nancy McWilliams, Robert Michels, George Stricker, and Robert Wallerstein, for their comments on earlier drafts. Visit “Jonathan Shedler, Ph.D.” on Facebook or send email correspondence to [email protected].

J. Shedler, PhD (*) Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA e-mail: [email protected] R.A. Levy et al. (eds.), Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence, Current Clinical Psychiatry, DOI 10.1007/978-1-60761-792-1_2, © Springer Science+Business Media, LLC 2012

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This chapter brings together findings from several empirical literatures that bear on the efficacy of psychodynamic treatment. It will first outline the distinctive features of psychodynamic psychotherapy. It will next review empirical evidence for the efficacy of psychodynamic treatment, including evidence that patients who receive psychodynamic psychotherapy not only maintain therapeutic gains but continue to improve over time. Finally, it will consider evidence that nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize interventions that have long been central to psychodynamic theory and practice.

Distinctive Features of Psychodynamic Technique Psychodynamic or psychoanalytic psychotherapy1 refers to a range of treatments based on psychoanalytic concepts and methods that involve less frequent meetings and may be considerably briefer than psychoanalysis proper. Session frequency is typically once or twice per week, and the treatment may be either time limited or open ended. The essence of psychodynamic psychotherapy is exploring those aspects of self that are not fully known, especially as they are manifested and potentially influenced in the therapy relationship. Undergraduate textbooks too often equate psychoanalytic or psychodynamic therapies with some of the more outlandish and inaccessible speculations made by Sigmund Freud roughly a century ago [1], rarely presenting mainstream psychodynamic concepts as understood and practiced today. Such presentations, along with caricatured depictions in the popular media, have contributed to widespread misunderstanding of psychodynamic treatment; for discussion of how clinical psychoanalysis is represented and misrepresented in undergraduate curricula, see [2–5]. To help dispel possible myths and facilitate greater understanding of psychodynamic practice, this section reviews core features of contemporary psychodynamic technique. Blagys and Hilsenroth [6] conducted a search of the PsycLit database to identify empirical studies that compared the process and technique of manualized psychodynamic psychotherapy with that of manualized cognitive behavioral therapy. Seven features reliably distinguished psychodynamic therapy from other therapies, as determined by empirical examination of actual session recordings and transcripts; note that the features listed in the following text concern process and technique only, not underlying principles that inform these techniques; for a discussion of concepts and principles, see [7–9]: 1. Focus on affect and expression of emotion. Psychodynamic psychotherapy encourages exploration and discussion of the full range of a patient’s emotions. The therapist helps the patient describe and put words to feelings, including contradictory feelings, feelings that are troubling or threatening, and feelings that the patient may not initially be able to recognize or acknowledge (this stands in contrast to a cognitive focus, where the greater emphasis is on thoughts and beliefs; [10, 11]). There is also a recognition that intellectual insight is not the same as emotional insight which resonates at a deep level and leads to change; this is one reason why many intelligent and psychologically minded people can explain the reasons for their difficulties, yet their understanding does not help them overcome those difficulties. 2. Exploring attempts to avoid distressing thoughts and feelings. People do a great many things, knowingly and unknowingly, to avoid aspects of experience that are troubling. This avoidance (in theoretical terms, defense and resistance) may take coarse forms, such as missing sessions, arriving late, or being evasive. It may take subtle forms that are difficult to recognize in ordinary social discourse, such as subtle shifts of topic when certain ideas arise, focusing on incidental aspects of

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I use the terms psychodynamic and psychoanalytic interchangeably.

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an experience rather than on what is psychologically meaningful, attending to facts and events to the exclusion of affect, focusing on external circumstances rather than one’s own role in shaping events, and so on. Psychodynamic psychotherapists actively focus on and explore avoidances. Identifying recurring themes and patterns. Psychodynamic psychotherapists work to identify and explore recurring themes and patterns in patients’ thoughts, feelings, self-concept, relationships, and life experiences. In some cases, a patient may be acutely aware of recurring patterns that are painful or self-defeating but feel unable to escape them (e.g., a man who repeatedly finds himself drawn to romantic partners who are emotionally unavailable; a woman who regularly sabotages herself when success is at hand). In other cases, the patient may be unaware of the patterns until the therapist helps him or her recognize and understand them. Discussion of past experience (developmental focus). Related to identifying of recurring themes and patterns is the recognition that past experience, especially early experiences of attachment figures, affects our relation to, and experience of, the present. Psychodynamic psychotherapists explore early experiences, the relation between past and present, and the ways in which the past tends to “live on” in the present. The focus is not on the past for its own sake, but rather on how the past sheds light on current psychological difficulties. The goal is to help patients free themselves from the bonds of past experience in order to live more fully in the present. Focus on interpersonal relations. Psychodynamic psychotherapy places heavy emphasis on patients’ relationships and interpersonal experience (in theoretical terms, object relations and attachment). Both adaptive and nonadaptive aspects of personality and self-concept are forged in the context of attachment relationships, and psychological difficulties often arise when problematic interpersonal patterns interfere with a person’s ability to meet emotional needs. Focus on the therapy relationship. The relationship between therapist and patient is itself an important interpersonal relationship, one that can become deeply meaningful and emotionally charged. To the extent that there are repetitive themes in a person’s relationships and manner of interacting, these themes tend to emerge in some form in the therapy relationship. For example, a person prone to distrust others may view the therapist with suspicion; a person who fears disapproval, rejection, or abandonment may fear rejection by the therapist, whether knowingly or unknowingly; a person who struggles with anger and hostility may struggle with anger toward the therapist; and so on (these are relatively crude examples; the repetition of interpersonal themes in the therapy relationship is often more complex and subtle than these examples suggest). The recurrence of interpersonal themes in the therapy relationship (in theoretical terms, transference and countertransference) provides a unique opportunity to explore and rework them in vivo. The goal is greater flexibility in interpersonal relationships and an enhanced capacity to meet interpersonal needs. Exploration of wishes and fantasies. In contrast to other therapies where the therapist may actively structure sessions or follow a predetermined agenda, psychodynamic psychotherapy encourages patients to speak freely about whatever is on their minds. When patients do this (and most patients require considerable help from the therapist before they can truly speak freely), their thoughts naturally range over many areas of mental life, including desires, fears, fantasies, dreams, and daydreams (which in many cases the patient has not previously attempted to put into words). All of this material is a rich source of information about how the person views self and others, interprets and makes sense of experience, avoids aspects of experience, or interferes with a potential capacity to find greater enjoyment and meaning in life.

The last sentence hints at a larger goal that is implicit in all of the others: The goals of psychodynamic psychotherapy include, but extend beyond, symptom remission. Successful treatment should not only relieve symptoms (i.e., get rid of something) but also foster the positive presence of psychological capacities and resources. Depending on the person and the circumstances, these might include the capacity to have more fulfilling relationships, make more effective use of one’s talents and abilities, maintain a realistically based sense of self esteem, tolerate a wider range of affect, have

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more satisfying sexual experiences, understand self and others in more nuanced and sophisticated ways, and face life’s challenges with greater freedom and flexibility. Such ends are pursued through a process of self reflection, self exploration, and self discovery that takes place in the context of a safe and deeply authentic relationship between therapist and patient. (For a jargon-free introduction to contemporary psychodynamic thought, see That was Then, This is Now: An Introduction to Contemporary Psychodynamic Therapy ([7]; freely available for download at http://psychsystems. net/shedler.html [12]).

How Effective Is Psychotherapy in General? In psychology and in medicine more generally, meta-analysis is a widely accepted method for summarizing and synthesizing the findings of independent studies [13–15]. Meta-analysis makes the results of different studies comparable by converting findings into a common metric, allowing findings to be aggregated or pooled across studies. A widely used metric is effect size, which is the difference between treatment and control groups, expressed in standard deviation units.2 An effect size of 1.0 means that the average treated patient is one standard deviation healthier on the normal distribution or bell curve than the average untreated patient. An effect size of .8 is considered a large effect in psychological and medical research, an effect size of .5 is considered a moderate effect, and an effect size of .2 is considered a small effect [17]. The first major meta-analysis of psychotherapy outcome studies included 475 studies and yielded an overall effect size (various diagnoses and treatments) of .85 for patients who received psychotherapy compared to untreated controls [18]. Subsequent meta-analyses have similarly supported the efficacy of psychotherapy. The influential review by Lipsey and Wilson [19] tabulated results for 18 meta-analyses concerned with general psychotherapy outcomes, which had a median effect size of .75. It also tabulated results for 23 meta-analyses concerned with outcomes in cognitive behavioral therapy (CBT) and behavior modification, which had a median effect size of .62. A meta-analysis by Robinson et al. [20] summarized the findings of 37 psychotherapy studies concerned specifically with outcomes in the treatment of depression, which had an overall effect size of .73. These are relatively large effects. (For a review of psychotherapy efficacy and effectiveness research, see [21]). To provide some points of reference, it is instructive to consider effect sizes for antidepressant medications. An analysis of FDA databases (published and unpublished studies) reported in the New England Journal of Medicine found effect sizes of .26 for fluoxetine (Prozac), .26 for sertraline (Zoloft), .24 for citalopram (Celexa), .31 for escitalopram (Lexapro), and .30 for duloxetine (Cymbalta). The overall mean effect size for antidepressant medications approved by the FDA between 1987 and 2004 was .31 [22].3 A meta-analysis reported in the prestigious Cochrane Library [24] found an effect size of .17 for tricyclic antidepressants compared to active placebo (an active placebo mimics the side effects of an antidepressant drug but is not itself an antidepressant).4

2

This score, known as the standardized mean difference, is used to summarize the findings of randomized control trials. More broadly, the concept effect size may refer to any measure that expresses the magnitude of a research finding [16]. 3 The measure of effect size in this study was Hedges’ g [23] rather than Cohen’s d [17] which is more commonly reported. The two measures are based on slightly different computational formulas, but in this case, the choice of formula would have made no difference: “Because of the large sample size (over 12,000), there is no change in going from g to d; both values are .31 to two decimal places” (Rosenthal R, Personal communication to Marc Diener). 4 Although antidepressant trials are intended to be double-blind, the blind is easily penetrated because the adverse effects of antidepressant medications are physically discernable and widely known. Study participants and their doctors can therefore figure out whether they are receiving medication or placebo, and effects attributed to medication may be inflated by expectancy and demand effects. Use of “active” placebos better protects the blind, and the resulting effect sizes are approximately half as large as those otherwise reported.

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13

These are relatively small effects. Methodological differences between medication trials and psychotherapy trials are sufficiently great that effect sizes may not be directly comparable, and the findings should not be interpreted as conclusive evidence that psychotherapy is more effective. Effect sizes for antidepressant medications are reported to provide reference points that will be familiar to many readers; for more comprehensive listings of effect size reference points, see, e.g., [19, 25].

How Effective Is Psychodynamic Psychotherapy? A recent and especially methodologically rigorous meta-analysis of psychodynamic psychotherapy, published by the Cochrane Library,5 included 23 randomized controlled trials of 1,431 patients [26]. The studies compared patients with a range of common mental disorders6 who received short-term (9 months post-treatment). In addition to change in general symptoms, the meta-analysis reported an effect size of .81 for change in somatic symptoms, which increased to 2.21 at long-term follow-up; an effect size of 1.08 for change in anxiety ratings, which increased to 1.35 at follow up; and an effect size of .59 for change in depressive symptoms, which increased to .98 at follow up.7 The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended. A meta-analysis reported in Archives of General Psychiatry included 17 high quality randomized controlled trials (RCTs) of short-term (average 21 sessions) psychodynamic psychotherapy, reporting an effect size of 1.17 for psychodynamic psychotherapy compared to controls [27]. The pretreatment to post-treatment effect size was 1.39, which increased to 1.57 at long-term follow-up, which was an average of 13 months post-treatment. Translating these effect sizes into percentage terms, the authors noted that patients treated with psychodynamic psychotherapy were “better off with regard to their target problems than 92% of the patients before therapy.” A newly released meta-analysis examined the efficacy of short-term psychodynamic psychotherapy for somatic disorders [28]. It included 23 studies involving 1,870 patients who suffered from a wide range of somatic conditions (e.g., dermatological, neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, genitourinary, immunological). The study reported an effect size of .69 for improvement in general psychiatric symptoms and .59 for improvement in somatic symptoms. Among studies that reported data on healthcare utilization, 77.8% reported significant reductions in healthcare utilization due to psychodynamic psychotherapy—a finding with potentially enormous implications for healthcare reform. A meta-analysis reported in the American Journal of Psychiatry examined the efficacy of both psychodynamic psychotherapy (14 studies) and CBT (11 studies) for personality disorders [29]. The meta-analysis reported pretreatment to post-treatment effect sizes using the longest term follow-up available. For psychodynamic psychotherapy (mean length of treatment was 37 weeks), the mean

5 More widely known in medicine than in psychology, the Cochrane Library was created to promote evidence-based practice and is considered a leader in methodological rigor for meta-analysis. 6 These included nonpsychotic symptom and behavior disorders commonly seen in primary care and psychiatric services, e.g., non bipolar depressive disorders, anxiety disorders, and somatoform disorders, often mixed with interpersonal or personality disorders [26]. 7 The meta-analysis computed effect sizes in a variety of ways. The findings reported here are based on the single method that seemed most conceptually and statistically meaningful (in this case, a random effects model, with a single outlier excluded). See the original source for more fine-grained analyses [26].

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follow-up period was 1.5 years, and the pretreatment to post-treatment effect size was 1.46. For CBT (mean length of treatment was 16 weeks), the mean follow-up period was 13 weeks, and the effect size was 1.0. The authors concluded that both treatments demonstrated effectiveness. A more recent review of short-term (average 30.7 sessions) psychodynamic psychotherapy for personality disorders included data from seven randomized controlled trials [30]. The study assessed outcome at the longest follow-up period available (an average of 18.9 months post-treatment) and reported an effect size of .91 for general symptom improvement (N = 7 studies) and .97 for improvement in interpersonal functioning (N = 4 studies). Two recent studies examined the efficacy of long-term psychodynamic treatment. A meta-analysis reported in the Journal of the American Medical Association [31, 32] compared long-term psychodynamic therapy (>1 year or 50 sessions) with shorter term therapies for the treatment of complex mental disorders (defined as multiple or chronic mental disorders, or personality disorders), yielding an effect size of .65 for longer term versus shorter term therapy.8 The pretreatment to post-treatment effect size was 1.03 for overall outcome, which increased to 1.25 at long-term follow up (P < .01), an average of 23 months post-treatment. Effect sizes increased from treatment completion to follow-up for all five outcome domains assessed in the study (overall effectiveness, target problems, psychiatric symptoms, personality functioning, and social functioning). A second meta-analysis, reported in the Harvard Review of Psychiatry, examined the effectiveness of long-term psychodynamic psychotherapy (average 150 sessions) for adult outpatients with a range of DSM diagnoses [33]. For patients with mixed/moderate pathology, the pretreatment to post-treatment effect was .78 for general symptom improvement, which increased to .94 at long-term follow-up, an average of 3.2 years posttreatment. For patients with severe personality pathology, the pretreatment to post-treatment effect was .94, which increased to 1.02 at long-term follow-up, an average of 5.2 years post-treatment. These meta-analyses represent the most recent and methodologically rigorous evaluations of psychodynamic psychotherapy. Especially noteworthy is the recurring finding that the benefits of psychodynamic psychotherapy not only endure but increase with time, a finding that has now emerged in at least five independent meta-analyses [26, 27, 31, 34, 35]. In contrast, the benefits of other (nonpsychodynamic) empirically supported therapies tend to decay over time for the most common disorders (e.g., depression, generalized anxiety; [35–38]).9 Table 2.1 summarizes the meta-analytic findings described previously and adds additional findings to provide further points of reference. Except as noted, effect sizes listed in the table are based on comparisons of treatment and control groups and reflect initial response to treatment (not longterm follow-up). Studies supporting the efficacy of psychodynamic psychotherapy span a range of conditions and populations. Randomized controlled trials support the efficacy of psychodynamic psychotherapy for depression, anxiety, panic, somatoform disorders, eating disorders, substance-related disorders, and personality disorders [39, 40]. Findings concerning personality disorders are particularly intriguing. A recent study of patients with borderline personality disorder [41] not only demonstrated treatment benefits that equaled or exceeded those of another evidence-based treatment, dialectical behavior therapy (DBT; [42]), but also showed changes in underlying psychological mechanisms (intrapsychic processes) believed to mediate symptom change in borderline patients (specifically, changes in reflective function and attachment organization; [43]). These intrapsychic changes occurred in patients who received psychodynamic psychotherapy but not in patients who received DBT.

8

The authors had initially reported a higher effect size [31]; the value of .65 reported here is the more conservative value reported in a subsequent publication [32]. 9 The exceptions to this pattern are specific anxiety conditions such as panic disorder and simple phobia, for which short-term, manualized treatments do appear to have lasting benefits [38].

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Table 2.1 Illustrative effect sizes from meta-analyses of treatment outcome studies Treatment type and reference Description General psychotherapy Smith, Glass, and Miller [18] Various therapies and disorders Lipsey and Wilson [19] Various therapies and disorders

15

Effect size .85 .75a

Robinson et al. [20]

Various therapies, for depression

.73

CBT and related therapies Lipsey and Wilson [19]

CBT and behavior therapy, various disorders

.62b

Haby et al. [102] Churchill et al. [103] Cuijpers et al. [104] Öst [105] Antidepressant medication Turner et al. [22] Moncrieff et al. [24] Psychodynamic psychotherapy Abbass et al. [26] Leichsenring et al. [27] Anderson and Lambert [34] Abbass, Kisely, and Kroenke [28] Messer and Abbass [30] Leichsenring and Leibing [29] Leichsenring and Rabung [31, 32] de Maat et al. [33]

CBT for depression, panic, and generalized anxiety CBT for depression Behavioral activation for depression Dialectical behavior therapy, primarily for borderline personality disorder FDA-registered studies of antidepressants approved between 1987 and 2004 Tricyclic antidepressants versus active placebo Various disorders, general symptom improvement Various disorders, change in target problems Various disorders and outcomes Somatic disorders, change in general psychiatric symptoms Personality disorders, general symptom improvement Personality disorders, pretreatment to post-treatment Long-term psychodynamic psychotherapy versus shorter-term therapies for complex mental disorders, overall outcome Long-term psychoanalytic psychotherapy, pretreatment to post-treatment

.68 1.0 .87 .58

N of studies or meta-analyses 475 studies 18 metaanalyses 37 studies 23 metaanalyses 33 studies 20 studies 16 studies 13 Studies

.31

74 studies

.17

9 studies

.97 1.17 .85 .69

12 studies 7 studies 9 Studies 8 studies

.91 1.46c .65

7 studies 14 studies 7 studies

.78c

10 studies

a

Median effect size across 18 meta-analyses (from [19], 1993, Table 2.1) Median effect size across 23 meta-analyses (from [19], 1993, Table 2.2) c Pretreatment to post-treatment (within group) comparison b

Such intrapsychic changes may account for long-term treatment benefits. A newly released study showed enduring benefits of psychodynamic psychotherapy 5 years after treatment completion (and 8 years after treatment initiation). At 5-year follow-up, 87% of patients who received “treatment as usual” continued to meet diagnostic criteria for borderline personality disorder, compared to 13% of patients who received psychodynamic psychotherapy [44]. No other treatment for personality pathology has shown such enduring benefits. These last findings must be tempered with the caveat that they rest on two studies and therefore cannot carry as much evidential weight as findings replicated in multiple studies conducted by independent research teams. More generally, it must be acknowledged that there are far more empirical outcome studies of other treatments, notably CBT, than of psychodynamic treatments. The discrepancy in sheer number of studies is traceable, in part, to the indifference to empirical research of earlier generations of psychoanalysts, a failing that continues to haunt the field and that contemporary investigators labor to address. A second caveat is that many psychodynamic outcome studies have included patients with a range of symptoms and conditions, rather than focusing on specific diagnostic categories (e.g., defined by Diagnostic and Statistical Manual of Mental Disorders [45] diagnostic criteria). To what

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extent this is a limitation is open to debate. A concern often raised about psychotherapy efficacy studies is that they use highly selected and unrepresentative patient samples and consequently, findings do not generalize to real-world clinical practice (e.g., [38]). Nor is there universal agreement that DSM diagnostic categories define discrete or homogeneous patient groups (given that psychiatric comorbidity is the norm, and diagnosable complaints are often embedded in personality syndromes; [46, 47]). Be that as it may, an increasing number of studies of psychodynamic treatments do focus on specific diagnoses (e.g., [39–41, 44, 48, 49]).

A Rose by Another Name: Psychodynamic Process in Other Therapies The “active ingredients” of therapy are not necessarily those presumed by the theory or treatment model. For this reason, randomized controlled trials that evaluate a therapy as a “package” do not necessarily provide support for its theoretical premises or for the specific interventions that derive from them. For example, the available evidence indicates that the mechanisms of change in cognitive therapy (CT) are not those presumed by the theory. Kazdin [50], reviewing the empirical literature on mediators and mechanisms of change in psychotherapy, concluded: “Perhaps we can state more confidently now than before that whatever may be the basis of changes with CT, it does not seem to be the cognitions as originally proposed” (p. 8). There are also profound differences in the way therapists practice, even therapists ostensibly providing the same treatment. What takes place in the clinical consulting room reflects the qualities and style of the individual therapist, the individual patient, and the unique patterns of interaction that develop between them. Even in controlled studies designed to compare manualized treatments, therapists interact with patients in different ways, implement interventions differently, and introduce processes not specified by the treatment manuals [51]. In some cases, investigators have had difficulty determining from verbatim session transcripts which manualized treatment was being provided [52]. For these reasons, studies of therapy “brand names” can be highly misleading. Studies that look beyond brand names by examining session videotapes or transcripts may reveal more about what is helpful to patients [50, 53, 54]. Such studies indicate that the active ingredients of other therapies include unacknowledged psychodynamic elements. One method of studying what actually happens in therapy sessions makes use of the Psychotherapy Process Q-Sort (PQS; [55]). The instrument consists of 100 variables that assess therapist technique and other aspects of therapy process based on specific actions, behaviors, and statements during sessions. In a series of studies, blind raters scored the 100 PQS variables from archival, verbatim session transcripts for hundreds of therapy hours from outcome studies of both brief psychodynamic and cognitive behavioral therapy [56, 57].10 In one study, the investigators asked panels of internationally recognized experts in psychoanalytic and cognitive behavioral therapy to use the PQS to describe “ideally” conducted treatments [56]. Based on the expert ratings, the investigators constructed prototypes of ideally conducted psychodynamic and cognitive behavioral therapy. The two prototypes differed considerably. The psychodynamic prototype emphasized unstructured, open-ended dialog (e.g., discussion of fantasies and dreams); identifying recurring themes in the patient’s experience; linking patient’s feelings and perceptions to past experiences; drawing attention to feelings regarded by the patient as unacceptable (e.g., anger, envy, excitement); pointing out defensive maneuvers; interpreting warded-off or unconscious wishes, feelings, or ideas; focusing on the therapy relationship as a topic of discussion; and drawing connections between the therapy relationship and other relationships.

10

The cognitive therapy study was an RCT for depression; the psychodynamic psychotherapy studies were panel studies for mixed disorders and for PTSD, respectively. See the original source for more detailed descriptions [55].

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The CBT prototype emphasized dialogue with a more specific focus, with the therapist structuring the interaction and introducing topics; the therapist functioning in a more didactic or teacher-like manner; the therapist offering explicit guidance or advice; discussion of the patient’s treatment goals; explanation of the rationale behind the treatment and techniques; focusing on the patient’s current life situation; focusing on cognitive themes such as thoughts and belief systems; and discussion of tasks or activities (“homework”) for the patient to attempt outside of therapy sessions.11 In three sets of archival treatment records (one from a study of cognitive therapy and two from studies of brief psychodynamic psychotherapy), the researchers measured therapists’ adherence to each therapy prototype, without regard to the treatment model the therapists believed they were applying [56]. Therapist adherence to the psychodynamic prototype predicted successful outcome in both psychodynamic and cognitive therapy. Therapist adherence to the CBT prototype showed little or no relation to outcome in either form of therapy. The findings replicated those of an earlier study which employed different methodology and also found that psychodynamic interventions, not CBT interventions, predicted successful outcome in both cognitive and psychodynamic treatments [57]. An independent team of investigators using different research methods also found that psychodynamic methods predicted successful outcome in cognitive therapy [58]. The study assessed outcomes in cognitive therapy conducted according to Beck’s treatment model [59], and the findings had been reported as evidence for the efficacy of cognitive therapy for depression [60].12 Investigators measured three variables from verbatim transcripts of randomly selected therapy sessions in a sample of 64 outpatients. One variable assessed quality of the working alliance (the concept working alliance or therapeutic alliance is now widely recognized and often considered a nonspecific or “common” factor in many forms of therapy; many do not realize that the concept comes directly from psychoanalysis and has played a central role in psychoanalytic theory and practice for over four decades; see [61, 62]). The second variable assessed therapist implementation of the cognitive treatment model (i.e., addressing distorted cognitions believed to cause depressive affect). The third variable, labeled experiencing, beautifully captures the essence of psychoanalytic process: “At the lower stages of [experiencing], the client talks about events, ideas, or others (Stage 1); refers to self but without expressing emotions (Stage 2); or expresses emotions but only as they relate to external circumstances (Stage 3). At higher stages, the client focuses directly on emotions and thoughts about self (Stage 4), engages in an exploration of his or her inner experience (Stage 5), and gains awareness of previously implicit feelings and meanings (Stage 6). The highest stage [7] refers to an ongoing process of in-depth self-understanding” ([58], p. 499; emphasis added). Especially noteworthy is the phrase gains awareness of previously implicit feelings and meanings. The term implicit refers, of course, to aspects of mental life that are not initially conscious. The construct measured by the scale hearkens back to the earliest days of psychoanalysis and its central goal of making the unconscious conscious [63].13 In this study of manualized cognitive therapy for depression, the following findings emerged: (1) Working alliance predicted patient improvement on all outcome measures. (2) Psychodynamic process (“experiencing”) predicted patient improvement on all outcome measures. (3) Therapist adherence to the cognitive treatment model (i.e., focusing on distorted cognitions) predicted poorer outcome. A subsequent study using different methodology replicated the finding that interventions aimed at cognitive change predicted poorer outcome [64]. However, discussion of interpersonal relations and exploration of past experiences with early caregivers—both core features of psychodynamic technique—predicted successful outcome.

11

See the original source for more complete descriptions of the two therapy prototypes [56]. The study is one of the archival studies analyzed by Jones and his associates [56, 57]. 13 Although the term “experiencing” derives from the humanistic therapy tradition, the phenomenon assessed by the scale – a trajectory of deepening self-exploration, leading to increased awareness of implicit or unconscious mental life – is the core defining feature of psychoanalysis and psychoanalytic psychotherapy. 12

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These findings should not be interpreted as indicating that cognitive techniques are harmful, and other studies have reported positive relations between CBT technique and outcome [65–67]. Qualitative analysis of the verbatim session transcripts suggested that the poorer outcomes associated with cognitive interventions were due to implementation of the cognitive treatment model in dogmatic, rigidly insensitive ways by certain of the therapists [58]. (No school of therapy appears to have a monopoly on dogmatism or therapeutic insensitivity. Certainly, the history of psychoanalysis is replete with examples of dogmatic excesses.) On the other hand, the findings do indicate that the more effective therapists facilitated therapeutic processes that have long been core, centrally defining features of psychoanalytic theory and practice. Other empirical studies have also demonstrated links between psychodynamic methods and successful outcome, whether or not the investigators explicitly identified the methods as “psychodynamic” (e.g., [68–76]).

The Flight of the Dodo The heading of this section is an allusion to what has come to be known in the psychotherapy research literature as the dodo bird verdict. After reviewing the psychotherapy outcome literatures of the time, Rosenzweig [77] and subsequently Luborsky, Singer, and Luborsky [78] reached the conclusion of the dodo bird in Alice in Wonderland: “Everyone has won and all must have prizes.” Outcomes for different therapies were surprisingly equivalent and no form of psychotherapy proved superior to any other. In rare instances where studies find differences between active treatments, the findings virtually always favor the preferred treatment of the investigators (the investigator allegiance effect; [79]). Subsequent research has done little to alter the Dodo bird verdict [21, 80]. For example, studies that have directly compared CBT with short-term psychodynamic psychotherapy for depression have failed to show greater efficacy for CBT over psychodynamic psychotherapy, or vice versa [48, 49]. Leichsenring [49] noted that both treatments appeared to qualify as empirically supported therapies (ESTs) according to the criteria specified by the American Psychological Association Division 12 Task Force [81, 82]. Some of the studies compared psychodynamic treatments of only eight sessions duration, which most practitioners would consider inadequate, with 16-session CBT treatments. Even in these studies, outcomes were comparable [83, 84]. There are many reasons why outcome studies may fail to show differences between treatments, even if important differences really exist. Others have discussed the limitations and unexamined assumptions of current research methods [38, 53, 85]. Here, I focus on one salient limitation: the mismatch between what psychodynamic psychotherapy aims to accomplish and what outcome studies typically measure. As noted earlier, the goals of psychodynamic psychotherapy include, but extend beyond, alleviation of acute symptoms. Psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility. Symptom-oriented outcome measures commonly used in outcome studies (e.g., the Beck Depression Inventory [86] or Hamilton Depression Rating Scale [87]) do not attempt to assess such inner capacities [54, 88]. Possibly, the Dodo bird verdict reflects a failure of researchers, psychodynamic and nonpsychodynamic alike, to adequately assess the range of phenomena that can change in psychotherapy. The Shedler–Westen Assessment Procedure (SWAP; [89–91]) represents one method of assessing the kinds of inner capacities and resources that psychotherapy may develop. The SWAP is a clinicianreport (not self-report) instrument that assesses a broad range of personality processes, both healthy and pathological. The instrument can be scored by clinicians of any theoretical orientation and

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Table 2.2 Definition of mental health items from the Shedler–Westen Assessment Procedure (SWAP-200) Is able to use his/her talents, abilities, and energy effectively and productively Enjoys challenges; takes pleasure in accomplishing things Is capable of sustaining a meaningful love relationship characterized by genuine intimacy and caring Finds meaning in belonging and contributing to a larger community (e.g., organization, church, neighborhood, etc.) Is able to find meaning and fulfillment in guiding, mentoring, or nurturing others Is empathic; is sensitive and responsive to other peoples’ needs and feelings Is able to assert him/herself effectively and appropriately when necessary Appreciates and responds to humor Is capable of hearing information that is emotionally threatening (i.e., that challenges cherished beliefs, perceptions, and self-perceptions) and can use and benefit from it Appears to have come to terms with painful experiences from the past; has found meaning in, and grown from such experiences Is articulate; can express self well in words Has an active and satisfying sex life Appears comfortable and at ease in social situations Generally finds contentment and happiness in life’s activities Tends to express affect appropriate in quality and intensity to the situation at hand Has the capacity to recognize alternative viewpoints, even in matters that stir up strong feelings Has moral and ethical standards and strives to live up to them Is creative; is able to see things or approach problems in novel ways Tends to be conscientious and responsible Tends to be energetic and outgoing Is psychologically insightful; is able to understand self and others in subtle and sophisticated ways Is able to find meaning and satisfaction in the pursuit of long-term goals and ambitions Is able to form close and lasting friendships characterized by mutual support and sharing of experiences

has demonstrated high reliability and validity relative to a wide range of criterion measures [89, 92]. The SWAP includes an empirically derived Healthy Functioning Index comprised of the items listed in Table 2.2, which define and operationalize mental health as consensually understood by clinical practitioners across theoretical orientations [90, 91]. Many forms of treatment, including medications, may be effective in alleviating acute psychiatric symptoms, at least in the short run. However, not all therapies aim at changing underlying psychological processes such as those assessed by the SWAP. (A working version of the SWAP, which generates and graphs T-scores for a wide range of personality traits and disorders, is available at www.SWAPassessment.org.) Researchers, including psychodynamically oriented researchers, have yet to conduct compelling outcome studies that assess changes in inner capacities and resources, but two studies raise intriguing possibilities and suggest directions for future research. One is a single case study of a woman diagnosed with borderline personality disorder, who was assessed with the SWAP by independent assessors (not the treating clinician) at the beginning of treatment and again after 2 years of psychodynamic psychotherapy [93]. In addition to meaningful decreases in SWAP scales that measure psychopathology, the patient’s SWAP scores showed an increased capacity for empathy and greater sensitivity to others’ needs and feelings; increased ability to recognize alternative viewpoints, even when emotions ran high; increased ability to comfort and soothe herself; increased recognition and awareness of the consequences of her actions; increased ability to express herself verbally; more accurate and balanced perceptions of people and situations; a greater capacity to appreciate humor; and, perhaps most importantly, she had come to terms with painful past experiences and had found meaning in them and grown from them. The patient’s score on the SWAP Healthy Functioning Index increased by approximately two standard deviations over the course of treatment. A second study used the SWAP to compare 26 patients beginning psychoanalysis with 26 patients completing psychoanalysis [94]. The latter group not only had significantly lower scores for SWAP

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items assessing depression, anxiety, guilt, shame, feelings of inadequacy, and fears of rejection, but significantly higher scores for SWAP items assessing inner strengths and capacities (Table 2.2). These included greater satisfaction in pursuing long-term goals, enjoyment of challenges and pleasure in accomplishments, ability to utilize talents and abilities, contentment in life’s activities, empathy for others, interpersonal assertiveness and effectiveness, ability to hear and benefit from emotionally threatening information, and resolution of past painful experiences. For the group completing psychoanalysis, the mean score on the SWAP Healthy Functioning Index was one standard deviation higher. Methodological limitations preclude drawing causal conclusions from these studies, but they suggest that psychodynamic psychotherapy may not only alleviate symptoms but also develop inner capacities and resources that allow a richer and more fulfilling life. Measures such as the SWAP could be incorporated in future randomized controlled trials, scored by independent assessors blind to treatment condition, and used to assess such outcomes. Whether or not all forms of therapy aim for such outcomes, or researchers study them, they are clearly the outcomes desired by many people who seek psychotherapy. Perhaps, this is why psychotherapists, irrespective of their own theoretical orientations, tend to choose psychodynamic psychotherapy for themselves [95].

Discussion One intent of this chapter was to provide an overview of some basic principles of psychodynamic psychotherapy for readers who have not been exposed to them, or, at least, who have not heard them presented by a contemporary practitioner who takes them seriously and uses them clinically. Another was to show that psychodynamic treatments have considerable empirically support. The empirical literature on psychodynamic treatments does, however, have significant limitations. First, the number of randomized controlled trials for other forms of psychotherapy, notably CBT, is considerably larger than that for psychodynamic psychotherapy, perhaps by an order of magnitude. Many of these trials, specifically the newer and better designed trials, are superior in methodological rigor (although some of the newest psychodynamic RCTs, e.g., [41], also meet the highest standards of methodological rigor). In too many cases, characteristics of patient samples have been too loosely specified, treatment methods have been inadequately specified and monitored, and control conditions have not been optimal (e.g., using wait-list controls or “treatment as usual” rather than active alternative treatments— a limitation that applies to research on empirically supported therapies more generally). These and other limitations of the psychodynamic research literature must be addressed by future research. The intent of this chapter is not to compare treatments or literatures, but to review the existing empirical evidence supporting psychodynamic treatments and therapy processes, which is often underappreciated. In writing this chapter, it was impossible not to be struck by a number of ironies. One is that academicians who dismiss psychodynamic approaches, sometimes in vehement tones, often do so in the name of science. Some advocate a science of psychology grounded exclusively in the experimental method. Yet, the same experimental method yields findings that support both psychodynamic concepts (e.g., [96]) and treatments. In light of the accumulation of empirical findings, blanket assertions that psychodynamic approaches lack scientific support (e.g., [97–99]) are no longer defensible. Presentations that equate psychoanalysis with dated concepts that last held currency in the psychoanalytic community in the early twentieth century are similarly misleading; they are at best uninformed and at worst disingenuous. A second irony is that relatively few clinical practitioners, including psychodynamic practitioners, are familiar with the research reviewed in this chapter. Many psychodynamic clinicians and educators seem ill-prepared to respond to challenges from evidence-oriented colleagues, students,

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utilization reviewers, or policy makers, despite the accumulation of high quality empirical evidence supporting psychodynamic concepts and treatments. Just as antipsychoanalytic sentiment may have impeded dissemination of this research in academic circles, distrust of academic research methods may have impeded dissemination in psychoanalytic circles; see [100]. Such attitudes are changing, but they cannot change quickly enough. Researchers also share responsibility for this state of affairs [7]. Many investigators take for granted that clinical practitioners are the intended consumers of clinical research (e.g., [81]), but many of the psychotherapy outcome studies and meta-analyses reviewed for this chapter are clearly not written for practitioners. On the contrary, they are densely complex and technical, and often seem written primarily for other psychotherapy researchers—a case of one hand writing for the other. As an experienced research methodologist and psychometrician, I must admit that deciphering some of these articles required hours of study and more than a few consultations with colleagues who conduct and publish outcome research. I am unsure how the average knowledgeable clinical practitioner could navigate the thicket of specialized statistical methods, clinically unrepresentative samples, investigator allegiance effects, inconsistent methods of reporting results, and inconsistent findings across multiple outcome variables of uncertain clinical relevance. If clinical practitioners are indeed the intended “consumers” of psychotherapy research, then psychotherapy research needs to be more consumer relevant [101]. With the caveats noted earlier, the available evidence indicates that effect sizes for psychodynamic psychotherapies are as large as those reported for other treatments that have been actively promoted as “empirically supported” and “evidence based.” It indicates that the (often unacknowledged) “active ingredients” of other therapies include techniques and processes that have long been core, centrally defining features of psychodynamic treatment. Finally, the evidence indicates that the benefits of psychodynamic treatment are lasting and not just transitory, and appear to extend well beyond symptom remission. For many people, psychodynamic psychotherapy may foster inner resources and capacities that allow richer, freer, and more fulfilling lives.

References 1. Freud S. Introductory lectures on psycho-analysis. The standard edition of the complete psychological works of Sigmund Freud 1917;16:241–463. 2. Bornstein R. Psychoanalysis in the undergraduate curriculum: the treatment of psychoanalytic theory in abnormal psychology texts. Psychoanal Psychol. 1988;5:83–93. 3. Bornstein R. Psychoanalysis in the undergraduate curriculum: an agenda for the psychoanalytic researcher. Accessed in 2010. Electronic publishing: http://www.columbia.edu/~hc137/prs/v4n1/v4n1!2.htm, 1995. 4. Hansell J. Writing an undergraduate textbook: an analyst’s strange journey. Psychologist-Psychoanalyst. 2005;24(4):37–8. Electronic publishing: http://www.division39.org/pdfs/PsychPsychoanalyst1004c.pdf. 5. Redmond J, Shulman M. Access to psychoanalytic ideas in American undergraduate institutions. J Am Psychoanal Assoc. 2008;56:391–408. 6. Blagys MD, Hilsenroth MJ. Distinctive activities of short-term psychodynamic-interpersonal psychotherapy: a review of the comparative psychotherapy process literature. Clin Psychol Sci Pract. 2000;7:167–88. 7. Shedler J. Why the scientist-practitioner schism won’t go away. The General Psychologist. 2006;41(2):9–10. Electronic publishing: http://www.apa.org/divisions/div1/archive.html. 8. McWilliams N. Psychoanalytic psychotherapy: a practitioner’s guide. NY: Guilford; 2004. 9. Gabbard GO. Long-term psychodynamic psychotherapy: a basic text. Washington, DC: American Psychiatric Publishing; 2004. 10. Blagys MD, Hilsenroth MJ. Distinctive activities of cognitive–behavioral therapy: a review of the comparative psychotherapy process literature. Clin Psychol Rev. 2002;22:671–706. 11. Burum BA, Goldfried MR. The centrality of emotion to psychological change. Clin Psychol Sci Pract. 2007; 14:407–13. 12. Shedler J. That was then, this is now: psychoanalytic psychotherapy for the rest of us. Accessed in 2010. Electronic publishing: http://psychsystems.net/shedler.html, 2005.

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J. Shedler

13. Lipsey MW, Wilson DB. Practical meta-analysis. Thousand Oaks: Sage; 2001. 14. Rosenthal R. Meta-analytic procedures for social research. Newbury Park: Sage; 1991. 15. Rosenthal R, DiMatteo MR. Meta-analysis: recent developments in quantitative methods for literature reviews. Annu Rev Psychol. 2001;52:59–82. 16. Rosenthal R, Rosnow RL. Essentials of behavioral research: methods and data analysis. 3rd ed. New York: McGraw-Hill; 2008. 17. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: Lawrence Earlbaum Associates; 1988. 18. Smith ML, Glass GV, Miller TI. The benefits of psychotherapy. Baltimore: Johns Hopkins University Press; 1980. 19. Lipsey MW, Wilson DB. The efficacy of psychological, educational, and behavioral treatment: confirmation from meta-analysis. Am Psychol. 1993;48:1181–209. 20. Robinson LA, Berman JS, Neimeyer RA. Psychotherapy for the treatment of depression: a comprehensive review of controlled outcome research. Psychol Bull. 1990;108:30–49. 21. Lambert MJ, Ogles BM. The efficacy and effectiveness of psychotherapy. In: Lambert M, editor. Bergin and Garfield’s handbook of psychotherapy and behavior change. 5th ed. NY: Wiley; 2004. 22. Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358:252–60. 23. Hedges LV. Estimation of effect size from a series of independent experiments. Psychol Bull. 1982;92:490–9. 24. Moncrieff J, Wessely S, Hardy R. Active placebos versus antidepressants for depression (review). Cochrane Database Syst Rev. 2004;1:CD003012. 25. Meyer GJ, Finn SE, Eyde LD, Kay GG, Moreland KL, Dies RR, Eisman EJ, Kubiszyn TW, Reed GM. Psychological testing and psychological assessment: a review of evidence and issues. Am Psychol. 2001; 56:128–65. 26. Abbass AA, Hancock JT, Henderson J, Kisely S. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2006;4:CD004687. 27. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry. 2004;61:1208–16. 28. Abbass A, Kisely S, Kroenke K. Short-term psychodynamic psychotherapy for somatic disorders: systematic review and meta-analysis of clinical trials. Psychother Psychosom. 2009;78:265–74. 29. Leichsenring F, Leibing E. The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry. 2003;160:1223–32. 30. Messer SB, Abbass AA. Evidence-based psychodynamic therapy with personality disorders. In: J. Magnavita, editor. Evidence-based treatment of personality dysfunction: principles, methods and processes. Washington, DC: American Psychological Association Press, 2010. 31. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. J Am Med Assoc. 2008;300:1551–65. 32. Leichsenring F, Rabung S. Analyzing effectiveness of long-term psychodynamic psychotherapy reply. J Am Med Assoc. 2009;301:932–3. 33. de Maat S, de Jonghe F, Schoevers R, Dekker J. The effectiveness of long-term psychoanalytic therapy: a systematic review of empirical studies. Harv Rev Psychiatry. 2009;17(1):1–23. 34. Anderson EM, Lambert MJ. Short-term dynamically oriented psychotherapy: a review and meta-analysis. Clin Psychol Rev. 1995;15:503–14. 35. Gloaguen V, Cottraux J, Cucherat M, Blackburn I. A metaanalysis of the effects of cognitive therapy in depressed patients. J Affect Disord. 1998;49:59–72. 36. Hollon SD, DeRubeis RJ, Shelton RC, et al. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch Gen Psychiatry. 2005;62:417–22. 37. Maat S, Dekker J, Schoevers R, de Jonghe F. Relative efficacy of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis. Psychother Res. 2006;16:562–72. 38. Westen D, Novotny CM, Thompson-Brenner H. The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. Psychol Bull. 2004;130:631–63. 39. Leichsenring F. Are psychodynamic and psychoanalytic therapies effective? Int J Psychoanal. 2005;86: 841–68. 40. Milrod B, Leon AC, Busch ZF, Rudden M, Schwalberg M, Clarkin J, Aronson A, Singer M, Turchin W, Klass ET, et al. A randomized control trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry. 2007; 164:265–72. 41. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164:922–8. 42. Linehan MM. Cognitive behavioral treatment of borderline personality disorder. New York: Guilford; 1993.

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The Efficacy of Psychodynamic Psychotherapy

23

43. Levy KN, Meehan KB, Kelly KM, Reynoso JS, Weber M, Clarkin JF, Kernberg OF. Change in attachment patterns and reflective function in a randomized control trial of transference focused psychotherapy for borderline personality disorder. J Consult Clin Psychol. 2006;74:1027–40. 44. Bateman A, Fonagy P. 8-year follow-up of patients treated tor borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry. 2008;165:631–8. 45. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. 46. Blatt SJ, Zuroff DC. Empirical evaluation of the assumptions in identifying evidence based treatments in mental health. Clin Psychol Rev. 2005;25:459–86. 47. Westen D, Gabbard G, Blagov P. Back to the future: personality structure as a context for psychopathology. In: Krueger RF, Tackett JL, editors. Personality and psychopathology. New York: Guilford; 2006. p. 335–84. 48. Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol. 2008;76:909–22. 49. Leichsenring F. Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: a meta-analytic approach. Clin Psychol Rev. 2001;21:401–19. 50. Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annu Rev Clin Psychol. 2007;3:1–27. 51. Elkin I, Shea T, Watkins JT, Imber SD, Sotsky SM, Collins JF, Glass DR, Pilkonis PA, Leber WR, Docherty JP, Fiester SJ, Parloff MB. National institutes of mental health treatment of depression collaborative research program. Arch Gen Psychiatry. 1989;46:971–82. 52. Ablon JS, Jones EE. Validity of controlled clinical trials of psychotherapy: findings from the NIMH treatment of depression collaborative research program. Am J Psychiatry. 2002;159:775–83. 53. Goldfried MR, Wolfe BE. Psychotherapy practice and research: repairing a strained alliance. Am Psychol. 1996;51:1007–16. 54. Kazdin AE. Evidence-based treatment and practice: new opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. Am Psychol. 2008;63:146–59. 55. Jones EE. Therapeutic action: a guide to psychoanalytic therapy. Northvale: Jason Aronson; 2000. 56. Ablon JS, Jones EE. How expert clinicians’ prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitive-behavioral therapy. Psychother Res. 1998;8:71–83. 57. Jones EE, Pulos SM. Comparing the process in psychodynamic and cognitive behavioral therapies. J Consult Clin Psychol. 1993;61:306–16. 58. Castonguay LG, Goldfried MR, Wiser SL, Raue PJ, Hayes AM. Predicting the effect of cognitive therapy for depression: a study of unique and common factors. J Consult Clin Psychol. 1996;64:497–504. 59. Beck AT, Rush AJ, Shaw BF, Emory G. Cognitive therapy of depression. NY: Guilford; 1979. 60. Hollon SD, DeRubeis RJ, Evans MD, Wiemer MJ, Garvey MJ, Grove MW, Tuasn VB. Cognitive therapy and pharmacotherapy for depression: singly and in combination. Arch Gen Psychiatry. 1992;49:774–81. 61. Greenson RR. The technique and practice of psychoanalysis. New York: International Universities Press; 1967. 62. Horvath AO, Luborsky L. The role of the therapeutic alliance in psychotherapy. J Consult Clin Psychol. 1993; 61:561–73. 63. Freud S. Further remarks on the neuro-psychoses of defence. The standard edition of the complete psychological works of Sigmund Freud. 1896;3:157–185. 64. Hayes AM, Castonguay LG, Goldfried MR. Effectiveness of targeting the vulnerability factors of depression in cognitive therapy. J Consult Clin Psychol. 1996;64:623–7. 65. Feeley M, DeRubeis RJ, Gelfand LA. The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression. J Consult Clin Psychol. 1999;67:578–82. 66. Strunk DR, DeRubeis RJ, Chiu AW, Alvarez J. Patients’ competence in and performance of cognitive therapy skills: relation to the reduction of relapse risk following treatment for depression. J Consult Clin Psychol. 2007; 75:523–30. 67. Tang T, DeRubeis R. Sudden gains and critical session in cognitive-behavioral therapy for depression. J Consult Clin Psychol. 1999;67:894–904. 68. Barber J, Crits-Christoph P, Luborsky L. Effects of therapist adherence and competence on patient outcome in brief dynamic therapy. J Consult Clin Psychol. 1996;64:619–22. 69. Diener MJ, Hilsenroth MJ, Weinberger J. Therapist affect focus and patient outcomes in psychodynamic psychotherapy: a meta-analysis. Am J Psychiatry. 2007;164:936–41. 70. Gaston L, Thompson L, Gallagher D, Cournoyer L, Gagnon R. Alliance, technique, and their interactions in predicting outcome of behavioral, cognitive, and brief dynamic therapy. Psychother Res. 1998;8:190–209. 71. Hayes A, Strauss J. Dynamic systems theory as a paradigm for the study of cognitive change in psychotherapy: an application of cognitive therapy for depression. J Consult Clin Psychol. 1998;66:939–47.

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J. Shedler

72. Hilsenroth M, Ackerman S, Blagys M, Baity M, Mooney M. Short-term psychodynamic psychotherapy for depression: an evaluation of statistical, clinically significant, and technique specific change. J Nerv Ment Dis. 2003;191:349–57. 73. Høglend P, Bøgwald KP, Amlo S, Marble A, Ulberg R, et al. Transference interpretations in dynamic psychotherapy: do they really yield sustained effects? Am J Psychiatry. 2008;165:763–71. 74. Norcross JC, editor. Psychotherapy relationships that work: therapist contributions and responsiveness to patients. NY: Oxford University Press; 2002. 75. Pos AE, Greenberg LS, Goldman RN, Korman LM. Emotional processing during experiential treatment of depression. J Consult Clin Psychol. 2003;71:1007–16. 76. Vocisano C, Klein DN, Arnow B, Rivera C, Blalock JA, Rothbaum B, Vivian D, Markowitz JC, Kocsis JH, Manber R, Castonguay L, Rush AJ, Borian F, McCullough JP, Kornstein SG, Riso LP, Thase ME. Therapist variables that predict change in psychotherapy with chronically depressed outpatients. Psychotherapy. 2004;41: 255–65. 77. Rosenzweig S. Some implicit common factors in diverse methods of psychotherapy. Am J Orthopsychiatry. 1936;6:412–5. 78. Luborsky L, Singer B, Luborsky L. Comparative studies of psychotherapy. Arch Gen Psychiatry. 1975;32: 995–1008. 79. Luborsky L, Diguer L, Seligman DA, Rosenthal R, Krause ED, Johnson S, Halperin G, Bishop M, Berman JS, Schweizer E. The researcher’s own therapy allegiances: a “wild card” in comparisons of treatment efficacy. Clin Psychol Sci Pract. 1999;6:95–106. 80. Wampold BE, Minami T, Baskin TW, Callen ST. A meta-(re)analysis of the effects of cognitive therapy versus “other therapies” for depression. J Affect Disord. 2002;68:159–65. 81. Task Force on Promotion and Dissemination of Psychological Procedures. Training in and dissemination of empirically-validated treatments: report and recommendations. The Clinical Psychologist. 1995;48:3–23. 82. Chambless DL, Baker M, Baucom DH, Beutler LE, Calhoun KS, et al. Update on empirically validated therapies, II. The Clinical Psychologist. 1998;51:3–16. 83. Barkham M, Rees A, Shapiro DA, Stiles WB, Agnew RM, Halstead J, Culverwell A, Harrington VMG. Outcomes of time-limited psychotherapy in applied settings: replication of the second Sheffield psychotherapy project. J Consult Clin Psychol. 1996;64:1079–85. 84. Shapiro DA, Barkham M, Rees A, Hardy GE, Reynolds S, Startup M. Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol. 1994;62:522–34. 85. Norcross JC, Beutler LE, Levant RF, editors. Evidence based practices in mental health: debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association; 2005. 86. Beck AT, Ward CH, Mendelson M, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71. 87. Hamilton MA. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–61. 88. Blatt SJ, Auerbach JS. Psychodynamic measures of therapeutic change. Psychoanal Inq. 2003;23:268–307. 89. Shedler J, Westen D. The Shedler–Westen assessment procedure (SWAP): making personality diagnosis clinically meaningful. J Pers Assess. 2007;89:41–55. 90. Westen D, Shedler J. Revising and assessing axis II, part 1: developing a clinically and empirically valid assessment method. Am J Psychiatry. 1999;156:258–72. 91. Westen D, Shedler J. Revising and assessing axis II, part 2: toward an empirically based and clinically useful classification of personality disorders. Am J Psychiatry. 1999;156:273–85. 92. Westen D, Shedler J. Personality diagnosis with the Shedler–Westen assessment procedure (SWAP): integrating clinical and statistical measurement and prediction. J Abnorm Psychol. 2007;116:810–22. 93. Lingiardi V, Shedler J, Gazillo F. Assessing personality change in psychotherapy with the SWAP-200: a case study. J Pers Assess. 2006;86:23–32. 94. Cogan R, Porcerelli JH. Clinician reports of personality pathology of patients beginning and patients ending psychoanalysis. Psychol Psychother Theor Res Pract. 2005;78(2):235–48. 95. Norcross JC. The psychotherapist’s own psychotherapy: educating and developing psychologists. Am Psychol. 2005;60:840–50. 96. Westen D. The scientific legacy of Sigmund Freud: toward a psychodynamically informed psychological science. Psychol Bull. 1998;124:333–71. 97. Barlow DH, Durand VM. Abnormal psychology: an integrative approach. 4th ed. Pacific Grove: Brooks/Cole; 2005. 98. Crews F. The verdict on Freud. Psychol Sci. 1996;7:63–7. 99. Kihlstrom JF. A tumbling ground for whimsies? Contem Psychol. 1999;44:376–8. 100. Bornstein R. The impending death of psychoanalysis. Psychoanal Psychol. 2001;18:3–20.

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101. Westen D, Novotny CM, Thompson-Brenner H. EBP ¹ EST: Reply to Crits-Christoph et al. (2005) and Weisz et al. (2005). Psychol Bull. 131:427–433. 102. Haby MM, Donnely M, Corry J, Vos T. Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome. Aust N Z J Psychiatry. 2006;40:9–19. 103. Churchill R, Hunot V, Corney R, Knapp M, McGuire H, Tylee A, Wessely S. A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression. Health Technol Assess. 2001;5:1–173. 104. Cuijpers P, van Straten A, Warmerdam L. Behavioral activation treatments of depression: a meta-analysis. Clin Psychol Rev. 2007;27:318–26. 105. Öst LG. Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis. Behav Res Ther. 2008;46:296–321.

Chapter 3

Effectiveness of Long-Term Psychodynamic Psychotherapy: First Meta-Analytic Evidence and Its Discussion Sven Rabung and Falk Leichsenring

Keywords Effectiveness • Efficacy • Mental disorders • Meta-analysis • Personality disorders • Psychoanalysis • Psychodynamic psychotherapy

Introduction The evidence base of psychodynamic psychotherapy is heterogeneous [1, 2]. For short-term psychodynamic psychotherapy (STPP) there is some evidence available supporting its efficacy for specific disorders [3–7]. For long-term psychodynamic psychotherapy (LTPP), however, evidentiary outcome research has been scarce for a long time [1, 2, 8]. According to existing evidence, it generally applies that shorter-term psychotherapy is sufficient for most subjects suffering from acute mental distress [9]. On the other hand, evidence also shows that short-term treatments are not sufficiently effective for a considerable proportion of patients with chronic mental disorders or personality disorders [9–11]. Some studies imply that longer-term psychotherapy may be helpful for these patients [9, 10, 12–16]. This should not only be true of (long-term) psychodynamic therapy, but also of other psychotherapeutic approaches that are usually short term (e.g., for CBT) [15, 16]. Evidence-based treatments for patients suffering from complex mental disorders are exceptionally important. Personality disorders, for example, are quite common in general and clinical populations and are significantly associated with functional impairment [17–19]. In addition, many patients in clinical populations suffer from not just a single, but multiple mental disorders. Again, this is significantly related to greater impairment in social and occupational functioning [20, 21]. Not least, the chronicity of a mental disorder can be expected to be another important factor influencing both impairment and prognosis.

S. Rabung, Ph.D. (*) Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Department of Psychology, University of Klagenfurt, Austria e-mail: [email protected] F. Leichsenring, DSc. Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany e-mail: [email protected] R.A. Levy et al. (eds.), Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence, Current Clinical Psychiatry, DOI 10.1007/978-1-60761-792-1_3, © Springer Science+Business Media, LLC 2012

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Some studies suggested that LTPP may be helpful for these groups of patients. Strong evidence-based support, however, has been lacking for a long time. Until the year 2008, no meta-analysis addressing the outcome of LTPP had been published, although preliminary data have been reported by Lamb [22]. This chapter reports about the first meta-analysis on the effectiveness of LTPP, published in the Journal of the American Medical Association in 2008 [23]. In addition, we will include an overview of the discussion raised after release of that paper (e.g. [24]).

First Meta-Analysis on the Effectiveness of LTPP Most meta-analyses usually address narrow research questions and, accordingly, use restricted inclusion criteria. Nevertheless, we attempted to meta-analytically and comprehensively compile all the existing evidence for LTPP for the first time. Thus, we decided to include as many studies as possible addressing the outcome of LTPP without a priori limiting our data collection on any specific form of LTPP, any specific patient group, or any specific control condition. A broad perspective on meta-analysis increases the power and generalizability and, consequently, the usefulness of results [25]. If results are not homogeneous, subgroup analysis can be carried out to examine the reasons. In line with the findings on dose–effect relationships described earlier, however, our metaanalysis placed special emphasis on complex mental disorders (i.e., personality disorders, chronic mental disorders, or multiple mental disorders). In order to maximize generalizability of results, this meta-analysis sought to include both studies with high internal validity (RCTs) and studies with high clinical representativeness (effectiveness studies) provided that they fulfilled predefined inclusion criteria. Against this background, our meta-analysis addressed the following research questions: 1. How effective is LTPP, especially in complex mental disorders? 2. Is LTPP superior to shorter or less intensive forms of psychotherapeutic treatments? 3. Which patient, treatment, or study characteristics are related to the outcome of LTPP?

Methods The meta-analysis has been carried out in accordance with recent guidelines for the reporting of meta-analyses [26, 27].

Definition of Long-Term Psychodynamic Psychotherapy Psychodynamic psychotherapy serves as an umbrella concept encompassing treatments that operate on a continuum of supportive–interpretive psychotherapeutic interventions. An emphasis is placed on more interpretive or supportive interventions depending on the patient’s needs [8, 28]. Gunderson and Gabbard defined LTPP as “… a therapy that involves careful attention to the therapist–patient interaction, with thoughtfully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the therapist’s contribution to the two-person field” ([8], p. 685). Regarding duration, there is no generally accepted “standard” for LTPP. In accordance with the definition given by Crits-Christoph and Barber ([29], p. 456) and other experts in the field, in our meta-analysis, we defined LTPP as lasting at least 1 year or 50 sessions.

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Inclusion Criteria and Selection of Studies We applied the following inclusion criteria (a) studies of LTPP meeting the definition given earlier, i.e., psychodynamic therapy lasting for at least 1 year or at least 50 sessions; (b) individual therapy; (c) clearly described samples of patients with mental disorders; (d) adult patients (at least 18 years of age); (e) prospective studies including pre- and post- or follow-up assessments (no retrospective studies, therapies must have been terminated); (f) reliable and valid outcome measures; (g) data to allow calculation of effect sizes; (h) concomitant (e.g., psychopharmacological) treatments were tolerable, but relevant studies were evaluated separately in order to control for effects of combined treatment versus LTPP alone; and (i) both efficacy and quasi-experimental effectiveness studies. These criteria are consistent with other recent meta-analyses of psychotherapy [5, 10]. We performed a computerized search using MEDLINE, PsycINFO, and Current Contents in order to collect studies of LTPP published between 1960 and May 2008. In addition, we performed manual searches in articles and textbooks and communicated with authors and experts in the field.

Data Extraction The two authors independently extracted the following information from the papers included: author names, publication year, psychiatric disorder treated, age and sex of patients, duration of treatment, number of sessions, type of comparison group, sample sizes, use of treatment manuals, general clinical experience of therapists, specific experience with the patient group under study, specific training of therapists, study design, duration of follow-up period, and use of psychotropic medication. Disagreements between raters were resolved by consensus. Since evidence suggests that blinding is unnecessary for meta-analyses [30], the raters were not blinded with regard to treatment condition. Finally, effect sizes were independently assessed by the two raters. Inter-rater reliability was satisfactory (r ³ 0.80) for all outcome domains under study (discussed next).

Assessment of Effect Sizes and Statistical Analysis We assessed effect sizes separately for target problems, general psychiatric symptoms, personality functioning, and social functioning. In addition, overall outcome was determined by averaging the effect sizes assessed in the four outcome domains in question. As outcome measures of target problems, we included both patient ratings of target problems [31] and measures referring to the symptoms specific to the patient group under study (e.g., a measure of impulsivity for studies examining borderline personality disorder). For general psychiatric symptoms, both broad measures of psychiatric symptoms such as the Symptom-Checklist SCL-90 [32] and specific measures that do not specifically refer to the disorder under study were included (e.g., an anxiety inventory applied in patients with personality disorders). For personality functioning, measures of personality characteristics (e.g., self-report inventories like the Defense Style Questionnaire) were included [33, 34]. Social functioning was assessed using the Social Adjustment Scale [35] and similar measures. If a study used more than one measure for one area of functioning (e.g., target problems), we assessed the effect size for each measure separately and calculated the mean effect size of these measures as the outcome in the respective area of functioning. If a study included more than one form of LTPP, each treatment condition was entered separately into the meta-analysis.

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As the universal outcome measure, that can be determined for both controlled and uncontrolled trials, we calculated within-group effect sizes for all studies and treatment conditions using Cohen’s d statistic as follows. For each measure, we subtracted the post-treatment mean from the pretreatment mean and divided the difference by the pretreatment standard deviation of the measure [36, 37]. If there was more than one treatment group, we calculated a pooled baseline standard deviation as suggested by Hedges and Rosenthal [37, 38]. If necessary, signs were reversed so that a positive effect size always indicated improvement. To examine the stability of psychotherapeutic effects, we assessed effect sizes separately for assessments at the termination of therapy and at follow-up. If there was more than one follow-up assessment, we included the one with the longest follow-up period. If data pertaining to completers and intent-to-treat samples were reported, we included the latter. To correct for bias related to small sample sizes, we calculated Hedges’ d statistic, an unbiased measure of effect size in small samples ([39, p. 81], formula 10). As a measure of between-group effect size, we used the point biserial correlation rp as suggested by Cohen and Rosenthal [36, 38]. The point biserial correlation also allowed us to test for differences between the within-group effect sizes of LTPP versus other forms of psychotherapy. As will be discussed later in more detail, this measure of a between-group effect size is not identical to that usually assessed in exclusively comparative meta-analyses since it considers treatment groups rather than patients as the unit of analysis. If the data necessary to calculate effect sizes were not published in an article, we asked the study authors for these data. We carried out tests for heterogeneity using the Q statistic [39]. The degree of heterogeneity was assessed by calculating the I 2 index [40]. In case of significant heterogeneity, we applied random-effect models [41, 42]. To control for publication bias, tests for asymmetry in funnel plots and file-drawer analyses were performed [42–44]. To test for differences between RCTs and effectiveness studies, we calculated point biserial correlations between type of study and effect size. Outcome data from RCTs and observational studies could only be combined if no significant differences exist. To analyze the effects of LTPP in complex mental disorders, we carried out subgroup analyses for (a) personality disorders, (b) chronic mental disorders, and (c) multiple mental disorders. Additional subgroup analyses were carried out to check for sensitivity. To test the impact of possible predictor or moderator variables on outcome (e.g., concomitant psychotropic medication, use of treatment manuals), we performed correlation analyses. To compare the effects of LTPP to those of other psychotherapeutic treatments, we performed comparative analyses for the subsample of studies providing a control group design. All statistical analyses were conducted using SPSS 15.0 [45] and MetaWin 2.0 [46]. Two-tailed tests of significance were carried out for all analyses. The significance level was defined to be p = 0.05 unless otherwise stated.

Assessment of Study Quality According to the inclusion criteria, only studies meeting defined quality standards were considered in our meta-analysis (only prospective studies, reliable and valid outcome measures, clearly described patient samples, adequate data). In addition, we assessed the quality of studies by use of a scale proposed by Jadad et al. [47]. This scale takes into account if a study was described as randomized, if a study was described as double blind, and if withdrawals and dropouts were described. In psychotherapy research, however, double blind studies cannot be realized, because the patients know or can easily find out which treatment they receive. Thus, all studies of psychotherapy would inevitably have to be given a score of zero points on this item. Instead of blinding therapists and patients, the respective requirement in psychotherapy research is that in case of observer-rated outcome measures, the ratings were carried out by raters blind to the treatment condition. Complementary, the patient perspective is of particular importance in psychotherapy. For this reason, outcome is often

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assessed by self-report instruments. In line with these considerations, we decided to score this item if outcome was assessed by blinded raters or by reliable self-report instruments. With this modification, the three items of the Jadad scale were independently rated by the two authors for all studies included. For the total score of the scale, we achieved a satisfactory inter-rater reliability (r = 0.84, p < 0.001).

Results Description of Studies Included Twenty-three separate studies published between 1984 and 2008 met the inclusion criteria [12–14, 34, 48–73]. The results of six of the studies were reported in two journal articles each [12–14, 34, 50, 52, 56, 57, 60, 61, 65, 66]. For all of these studies, we included the data from both articles in our analysis. The studies are described in Table 3.1. For eight of the studies, we received additional information from the authors [14, 53, 59, 60, 67, 69, 71, 73]. Five studies involved more than one LTPP treatment condition [49, 54, 56, 69, 72]. Each of these LTPP conditions was entered separately into our meta-analysis. For five studies, some control conditions had to be excluded from the meta-analysis for the following reasons [59, 60, 67–69]. The quasi-experimental comparison groups of the study by Rudolf et al. were not included in the meta-analysis because one comparison group could not be classified as either LTPP or STPP due to variability in treatment duration (5–200 sessions), the other condition represented inpatient treatment [68]. The CBT comparison group of the ongoing study by Huber et al. was not included because not enough data were available as yet [59]. For the Sandell et al. study, the low-dose therapy control group was not included, because data to calculate effect sizes were not available for this condition [69]. In the Knekt et al. study, assessments were made at predefined time points that did not exactly match end of therapy for the short-term treatment groups. Thus, the data of the shortterm psychotherapy groups were not included [60]. Finally, only two of the four treatment conditions compared by Piper et al. could be considered (i.e., the individual long-term and short-term conditions); the group treatments were not included due to our inclusion criteria [67]. In the study by Wilczek et al., not all of the patients under study met the criteria for an Axis I or Axis II diagnosis [73]. Hence, we included data only from those patients diagnosed with character pathology at intake.

Study Design Altogether, 11 RCTs [12, 14, 48, 53, 55, 56, 59, 60, 67, 71, 72] and 12 quasi-experimental studies could be included in the meta-analysis [34, 49, 51, 54, 62–65, 68–70, 73]. In all, eight controlled studies comparing LTPP to other methods of psychotherapy qualified to be included in the metaanalysis [12, 14, 48, 53, 55, 62, 67, 71].

Measures The outcome measures used in these studies are specified in Table 3.1, each with an indication to which outcome area it was assigned. For references of the instruments, the reader is referred to the original studies.

Eating disorders

Disorder

Anorexia nervosa

RCT

OBS-C Depressive and anxiety disordersd

RCT

Dare et al. [53]

Grande et al. [54]

Gregory et al. [55]

Borderline personality disorders

Chronic depression, anxiety, and/or personality disorders Borderline personality disorders Borderline personality disorders

RCT

Obsessive–compulsive personality disorders Borderline personality disorders

OBS-C Avoidant personality disorders

RCT

Type

Bond and OBS Perry [34, 50]c Clarkin OBS et al. [51]c Clarkin et al.; RCT Levy et al. [14, 52]c

Bateman and Fonagy [12, 13]c

Bachar et al. [48] Barber et al. [49]

Study (authors)

–

Psychodynamic focal therapy Dynamic deconstructive psychotherapy

Treatment as usual (TAU)

–

Psychoanalytic therapy

Cognitive-analytic therapy (CAT); family therapy (FT); routine treatment (TAU)

310 sessions, 44.2 months (1 year) 71.1 sessions, 24.2 months (1 year) 57.5 sessions, 12–18 months

24.9 sessions, 1 year

12 months

Dialectical-behavioral therapy (DBT); dynamic supportive treatment (DST)

Focal psychoanalytic psychotherapy

12 months

–

Transference-focused psychotherapy Transference-focused psychotherapy

110 sessions, 3 years

18 months

52 sessions

40 sessions, 12 months 52 sessions

LTPP

–

Psychiatric treatment as usual (TAU)

–

Cognitive therapy (CT); nutritional counseling (NC) –

Non-LTPP comparison

23

53

19

14

24

17

LTPP

88.7 sessions, 12–18 months

–

CAT: 12.9 sessions, 7 months; FT: 13.6 sessions, 1 year; TAU: 10.9 sessions, 1 year –

15

31

37

21

15

–

–

CAT: 22, FT: 22, TAU: 19

DBT: 30, DST: 30

–

–

19

–

CT: 17, NC: 10 –

Non-LTPP comparison

Sample size (N)a

DBT: 12 months; DST: 30 12 months

–

11.6 days inpatient treatment (90% of patients) plus 6 months partial hospitalization (72% of patients) –

–

CT: 12 months; NC: 6 months –

Non-LTPP comparison

Dose/duration of treatment (follow-up interval)

Dynamic psychotherapy

Supportive–expressive therapy Psychoanalytically oriented partial hospitalization

Self-psychological therapy Supportive–expressive therapy

LTPP

Treatment

Table 3.1 Studies of long-term psychodynamic psychotherapy (LTPP)

BEST (t), BDI (s), DES (s), SPS (so),% parasuicide,alcohol misuse, institutional caree

SCL-90-R (s), IIP (so)

Aggression scale(t), anger scale(t), Barrett scale (t), BDI (s), BSI (s), GAD (so), SAS (so), RF, coherence, resolution (p) BMI (t), ABW% (t), Morgan Russel (t)

Parasuicide (t), services (so)

SCL-90 (s), HRSD (s), GAF (so), DSQ (p)

BDI (s), SCL-90-R (s), IIP (so), STAI-state (s), STAI-trait: (p)

DSM-SS (t), EAT 26 (t), SCL-90 (s), Selves Q (p) WISPI (t), BAI (s), BDI (s), HARS (s), HRSD (s), IIP (so), % Diagnosis

Outcome measures (domains)b

Stevenson and OBS Meares [70] Svartberg RCT et al. [71]

OBS-C Heterogeneous disorders

Sandell et al. [69]

Borderline personality disorders Cluster C personality disorders

Depressive, anxiety, and personality disordersd

OBS

Rudolf et al. [68]

Heterogeneous disorders; 30% personality disorders

RCT

Personality disorders

Piper et al. [67]

Luborsky OBS et al. [64] Monsen OBS et al. [65, 66]

Borderline personality disorders Depressive, anxiety, and personality disordersd Heterogeneous disorders

Depressive or anxiety disorders

RCT

Korner OBS et al. [62] Leichsenring OBS et al. [63]

Depressive disorders

RCT

Huber and Klug [59] Knekt et al. [60, 61]c

Depressive, anxiety, and personality disordersd

Disorder

RCT

Type

Høglend et al. [56, 57]

Study (authors)

Cognitive therapy (CT)

–

–

Psychodynamic psychotherapy Self-psychological psychotherapy Dynamic psychotherapy

Psychoanalysis

Psychodynamic focal therapy (PFT)f; Psychodynamically oriented inpatient treatment (POI)f Lower-dose therapiesf

Short-term psychodynamic psychotherapy (STPP)

–

–

Psychoanalytic therapy

Psychoanalytically oriented psychotherapy

Psychodynamic psychotherapy

Psychoanalysis

40 sessions, 16.9 months (6, 12, 24 months)

54 months (1 year, 2 years) 43 months (1 year, 2 years) 12 months

265 sessions

76 sessions (6 months)

25.4 months (5 years)

> 50 sessions

40 sessions, 18.3 months (6, 12, 24 months)

–

–

21 months

PFT: 5–200 sessions; POI: 2.6 months

22 sessions (6 months)

–

–

–

253 sessions, 37.4 months (1 year)

12 months

60.6 sessions, 19.4 months STPP: 18.5 sessions 5.7 months; SFT: 9.8 sessions over up to 7.5 months 12 months

–

–

Non-LTPP comparison

229 sessions, 48.8 months 232 sessions, up to 3 years

33 sessions, 1 year (1 year, 2 years)

–

Psychodynamic focal therapyf Short-term psychodynamic psychotherapy (STPP)f; solution-focused therapy (SFT)f Treatment as usual (TAU)

33 sessions, 1 year (1 year, 2 years)

LTPP

Dose/duration of treatment (follow-up interval)

–

Non-LTPP comparison

Psychotherapy using the conversational model Psychoanalytic therapy –

Psychodynamic psychotherapy

Dynamic psychotherapy with transference interpretation Dynamic psychotherapy with no transference interpretation Psychoanalytic therapy

LTPP

Treatment

25

30

100

24

44

30

25

17

36

29

128

35

48

52

LTPP

25

–

–

27

PFT: 56, POI: 164

27

–

–

–

31

STPP: 101, SFT: 97

8

–

–

Non-LTPP comparison

Sample size (N)a

(continued)

DSM-III score (t), Cornell (s), behavior (so) Millon (t), SCL-90-R (s), IIP (so)

SCL-90-R (s), SOCS (p), SAS (so)

Affect (t), MMPI (t), (D + Pt + Si) (s), (F + pa + sc) (p) TSP (t), TSPI (t), TSIA (t), TSIAI (t), TSTI (t), Cornell (s), DA (s), CATT (p), BSP (so), IBSD (so), SSIAM (so) PSKB-SE 1(s), PSKB-SE 2 (p)

GAF (so), HSRS (so)

BDI (t), SCL-90-R (s), IIP (so) BDI (t), HDRS (t), HARD (t), SCL-Anx (t), SCL-90-R (s), Work (so), SAS-W (so), perceived social (so) DSM-III-R score (t), GAF (so) GAS (t), SCL-90-R (s), FLZ (p), IIP (so)

Psychodn. F Sc (t), SCL-90-R (s), IIP (so), GAF (so)

Outcome measures (domains)b

Personality disorders

Disorder –

–

Community-delivered psychodynamic therapy Psychoanalytic psychotherapy

Non-LTPP comparison

Manualized psychodynamic therapy

LTPP

Treatment

–

³1 year (1 year, – 3 years) 159 sessions (6 months)–

³1 year (1 year, 3 years)

LTPP

Non-LTPP comparison

Dose/duration of treatment (follow-up interval)

76

80

LTPP

–

–

Non-LTPP comparison

Sample size (N)a

DSM-IV score (t), SCL-90-T (s), GAF (so), change in diagnosise

Outcome measures (domains)b

Wilczek et al. [73]

OBS

Heterogeneous disorders; – 55 – KAPP (t), CPR-S-Ae, GAFe only character pathology patients included Note: RCT randomized controlled trial, OBS observational study, OBS-C observational study with control group a No. of patients for intention to treat samples stated, if data available b Outcome domains: t target problems, s symptoms, p personality, so social functioning. Measures: ABW average body weight, BAI Beck anxiety inventory, BDI Beck depression inventory, BEST borderline evaluation of severity over time, BMI body mass index, BSI brief symptom inventory, CATT Cattel’s H scale, CPR-S-A self-rating scale for affective syndromes, DA depression–anxiety subscale of psychiatric status schedule, DES dissociative experiences scale, D + Pt + Si subjective discomfort, anxiety, social introversion subscales of MMPI, DSM-III-R diagnostic and statistical manual of mental disorders (third edition revised), DSM-SS DSM symptomatology scale for anorexia and bulimia, DSQ defense style questionnaire, DST dynamic supportive treatment, EAT eating attitudes test, FLZ life satisfaction questionnaire, F + pa + sc F, projection, withdrawal subscales of MMPI, FT focal therapy, GAF global assessment of functioning scale, HARS Hamilton anxiety rating scale, HAMD Hamilton rating scale for depression, HSRS, health sickness rating scale, IBSD interpersonal behavior scale (discrepancy between present and ideal functioning), IBSP international behavior scale (present functioning), IIP inventory of interpersonal problems, KAPP Karolinska psychodynamic profile, MMPI Minnesota multiphasic personality inventory; NSLD number of sick-leave days, PFS psychodynamic functioning scales, PPFS perceived psychological functioning scale, PSKB-SE psychological and social-communicative state – self-report, RF reflexive function, SAS social adjustment scale, SAS-W work subscale of the social adjustment scale, SCL-90-R Symptom-Checklist-90 revised, SFT solution-focused therapy, SOCS sense of coherence scale, SPS social provisions scale, SSIAM structured and scaled interview to assess maladjustment, STAI state-trait anxiety inventory, TSIA and TSIAI, severity for all target objectives and most important objective, TSP and TSPI, severity for all target objectives and most important objective, TST and TSTI, severity for all target objectives and most important objective; WAI work ability index, WISPI Wisconsin personality disorders inventory, % diagnosis, percentage of patients fulfilling criteria for diagnosis. For further information on the outcome instruments, see original studies c LTPP combined with psychotropic medication in some patients of the sample d Predominant diagnoses in sample e These outcome measures not included (no data to calculate effect size d for the respective treatment or patient group) f Data of these comparison groups were not included in this meta-analysis

RCT

Type

Study (authors)

Vinnars et al. [72]c

(continued)

Table 3.1

3

Effectiveness of Long-Term Psychodynamic Psychotherapy…

35

Sample Size The 23 studies involved 1,053 patients treated with LTPP. For the comparative treatments, N = 257.

Mental Disorders The studies included cover a wide range of mental disorders (Table 3.1). Ten studies evaluated the effects of LTPP for patients with personality disorders [12–14, 34, 49, 51, 55, 62, 65, 70–72]. Nine studies examined patients with chronic mental disorders (defined as mental disorders lasting 1 year or longer) [34, 48, 53, 54, 59, 60, 63, 68, 69]. Multiple mental disorders (defined as two or more diagnoses of mental disorders) were treated in 14 studies [12, 14, 34, 49, 51, 54–56, 59, 63, 65, 68, 71, 72]. It is of note that these groups of studies overlap in part.

Treatment Manuals Treatment manuals or manual-like guidelines were applied in 12 studies [12, 14, 48, 49, 51, 53, 55, 56, 62, 70–72].

Therapy Duration The mean number of sessions carried out in the 23 studies of LTPP was 151.38 (SD = 154.98; median: 73.50). The mean duration of therapy was 94.81 weeks (SD = 58.79; median: 69.00).

Duration of Follow-up For LTPP, the mean follow-up period was 93.23 weeks (SD = 64.93).

Concomitant Psychotropic Medication Outcome data for LTPP alone – that is without any concomitant psychotropic medication – were reported for 16 of the 23 studies [48, 49, 53, 54, 56, 59, 62–65, 67–71, 73]. In seven studies, some patients received concomitant psychotropic medication as needed [12, 14, 34, 51, 55, 60, 72].

Overall Outcome To give a synopsis of the outcome achieved by LTPP in the 23 studies, Fig. 3.1 presents a forest plot listing the within-group, i.e., pre-treatment-to-post-treatment effect sizes of LTPP on overall outcome for each study. The effect sizes are displayed separately for RCTs and observational studies. A more detailed presentation of outcome data will be given later, following several paragraphs addressing the examination of possible sources of bias.

36

S. Rabung and F. Leichsenring

Study or sub-group

Sample size, No.

Effect size d Indicates Indicates (LCL; UCL) Deterioration Improvement

Randomized Controlled Trials Bachar (1999)

17

0.89 (0.18; 1.59)

Bateman (1999)

19

1.45 (0.73; 2.16)

Clarkin/Levy (2006)

30

0.89 (0.36; 1.42)

Dare (2001)

20

0.88 (0.23; 1.53)

Gregory (2008)

15

1.02 (0.26; 1.78)

Høglend (2006) [1]

52

0.96 (0.56; 1.37)

Høglend (2006) [2]

48

0.96 (0.54; 1.38)

Huber (2006)

35

1.74 (1.19; 2.29)

Knekt (2008)

128

1.07 (0.81; 1.33)

Piper (1984)

20

0.56 (-0.08; 1.19)

Svartberg (2004)

25

0.65 (0.08; 1.22)

Vinnars (2005) [1]

80

0.78 (0.46; 1.10)

Vinnars (2005) [2]

76

0.69 (0.36; 1.01)

565

0.94 (0.82; 1.06)

13

0.99 (0.18; 1.81)

Subtotal RCT Observational Studies Barber (1997) [1] Barber (1997) [2]

14

1.14 (0.34; 1.94)

Bond (2004)

41

0.56 (0.12; 1.01)

Clarkin (2001)

23

0.34 (-0.24; 0.93)

Grande (2006) [1]

32

1.36 (0.82; 1.91)

Grande (2006) [2]

27

0.78 (0.23; 1.34)

Korner (2006)

29

1.39 (0.82; 1.96)

Leichsenring (2005)

36

1.62 (1.09; 2.15)

Luborsky (2001)

17

0.96 (0.25; 1.67)

Monsen (1995)

23

1.38 (0.73; 2.02)

Rudolf (1994)

44

0.61 (0.19; 1.04)

Sandell (2000) [1]

24

1.04 (0.44; 1.65)

Sandell (2000) [2]

99

0.46 (0.18; 0.74)

Stevenson (1992)

30

1.34 (0.78; 1.90)

Wilczek (2004)

36

1.26 (0.75; 1.76)

488

0.99 (0.86; 1.12)

1053

0.96 (0.87; 1.05)

Subtotal OBS TOTAL

-0.5

0.0

0.5

1.0

1.5

2.0

2.5

Hedges’ d (95% CI)

Fig. 3.1 Effects of long-term psychodynamic psychotherapy (LTPP) on overall outcome (Adapted with permission from [23]. Copyright c American Medical Association)

3

Effectiveness of Long-Term Psychodynamic Psychotherapy…

37

Control for Heterogeneity The heterogeneity of the effects of LTPP was examined using the Q statistic [39, 46]. In addition, we assessed the degree of heterogeneity with the I 2 index [40]. For some outcome domains, the Q statistic was significant, thus indicating heterogeneity in some cases. This applied, for example, for overall outcome at post-treatment assessment in the total sample of 23 studies (Q = 53.71, p = 0.002; I 2 = 49%). In the controlled studies of LTPP, however, Q was only significant for two follow-up measures based on only two of the eight comparative studies (target problems: Q = 11.92, p = 0.001; I 2 = 92%; social functioning: Q = 4.53, p = 0.03; I 2 = 78%). At the time of post-treatment assessment, here, the I 2 index for overall outcome, target problems, general psychiatric symptoms, personality functioning, and social functioning was 0%, 45%, 46%, 60%, and 51%, respectively, indicating low to medium heterogeneity [74]. For follow-up, the number of studies providing data was too limited to calculate meaningful I 2 statistics. To account for any existing heterogeneity between studies, however, we used the random-effects model throughout all summary analyses.

Control for Publication Bias In the first instance, we tried to identify unpublished studies via the Internet and by contacting researchers in order to reduce the file-drawer effect. In addition, we tested for asymmetry in funnel plots by calculating Pearson correlations between effect size and sample size across studies. A significant correlation may indicate that larger effect sizes were more likely to be published [75]. Given the small number of studies with follow-up assessments, we confined this procedure to the posttreatment effect sizes. All correlations were insignificant (p > 0.30). As another test for publication bias, we assessed the fail-safe N for the post-treatment effect sizes [43]. A fail-safe number is the number of nonsignificant, unpublished or missing studies that would need to be added to a metaanalysis in order to change the results of the meta-analysis from significance to nonsignificance. For the 16 studies examining LTPP alone, for example, the fail-safe Ns were 921, 535, 623, and 358 for overall outcome, target problems, general symptoms, and social functioning, respectively. Only seven studies of LTPP alone provided data for outcome measures of personality functioning. The respective fail-safe N, here, was 42. Even this number is almost twice the number of studies we included in total. Summing up, we did not find any cogent indication of publication bias.

Control for Quality-Related Bias The relationship between study quality and outcome of LTPP was analyzed by calculating Pearson correlations between the total score of the Jadad scale and the within-group effect sizes for the different outcome domains. Again, only post-treatment effect sizes could be examined due to the small number of studies providing follow-up data. All correlations were nonsignificant (p > 0.28).

Control for Influence of Design Factors To test for possible differences between efficacy studies (RCTs) and effectiveness (observational) studies, we calculated point biserial correlations between type of study design (RCT = 1, effectiveness studies = 0) and the within-group effect size of LTPP at post-test. All correlations were nonsignificant (p > 0.36). Observational studies, thus, did not yield effect sizes significantly different from those of RCTs. This was the same for the comparison of controlled (including RCTs and studies using quasi-experimental control groups, cp. Table 3.1) and uncontrolled studies (p > 0.22).

38

S. Rabung and F. Leichsenring

Table 3.2 Effect sizes (d) of long-term psychodynamic psychotherapy (LTPP) alone across various mental disorders (16 studies) Number of LTPP Within-group effect Significance Outcome domain conditions (k)a size d (95% CI) (two-tailed test) Pre-therapy to post-therapy changes Overall effectiveness 20 1.03 (0.84–1.22)