Open door review

Experimental treatment studies

opendoorreview_banner-verlauf.jpg

Short-term psychodynamic psychotherapy and cognitive-behavioral therapy in generalized anxiety disorder: a randomized, controlled trial.

Leichsenring, F., Salzer, S., Jaeger, U., Kächele, H., Kreische, R., Leweke, F., . . . Leibing, E. (2009). Efficacy of short-term psychodynamic therapy and cognitive-behavioral therapy in generalized anxiety disorder: a randomized controlled trial. American Journal of Psychiatry, 166(8), 875-881.

Objective

While several studies have shown that cognitive-behavioral therapy (CBT) is an efficacious treatment for generalized anxiety disorder, few studies have addressed the outcome of short-term psychodynamic psychotherapy, even though this treatment is widely used. The aim of this study was to compare short-term psychodynamic psychotherapy and CBT with regard to treatment outcome in generalized anxiety disorder.

Method

Patients with generalized anxiety disorder according to DSM-IV were randomly assigned to receive either CBT (N=29) or short-term psychodynamic psychotherapy (N=28). Treatments were carried out according to treatment manuals and included up to 30 weekly sessions. The primary outcome measure was the Hamilton Anxiety Rating Scale, which was applied by trained raters blind to the treatment conditions. Assessments were carried out at the completion of treatment and 6 months afterward.

Results

Both CBT and short-term psychodynamic psychotherapy yielded significant, large, and stable improvements with regard to symptoms of anxiety and depression. No significant differences in outcome were found between treatments in regard to the primary outcome measure. These results were corroborated by two self-report measures of anxiety. In measures of trait anxiety, worry, and depression, however, CBT was found to be superior.

Conclusions

The results suggest that CBT and short-term psychodynamic psychotherapy are beneficial for patients with generalized anxiety disorder. In future research, large-scale multicenter studies should examine more subtle differences between treatments, including differences in the patients who benefit most from each form of therapy.

Contact

Prof. Dr. F. Leichsenring

Department of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Giessen, Germany.

E-mail: falk.leichsenring@psycho.med.uni-giessen.de

Munich Psychotherapy Study (MPS) – A three-year follow-up study: Psychoanalytic vs. psychodynamic therapy for depression

Huber, D., Henrich, G., Clarkin, J. & Klug, G. (2013). Psychoanalytic versus psychodynamic therapy for depression: a three-year follow-up study. Psychiatry, 76, 2, 132-149.

Brief Summary

The aim of this study was to investigate the effectiveness of long-term psychotherapies. In a prospective, randomized outcome study, psychoanalytic therapy (mean duration: 39 months, mean dose: 234 sessions) and psychodynamic therapy (mean duration: 34 months, mean dose: 88 sessions) were compared at post-treatment and at one-, two-, and three-year follow-up in the treatment of patients with a primary diagnosis of unipolar depression. All treatments were performed by experienced psychotherapists / psychoanalysts. Independent raters assessed treatment fidelity using the Psychotherapy Process Q-set. A two-tailed t-test yielded a significant difference in therapeutic technique between the therapy-groups. Primary outcome measures were the Beck Depression Inventory and the Scales of Psychological Capacities, and secondary outcome measures were Global Severity Index of the SCL-90-R, the Inventory of Interpersonal Problems, the Social Support Questionnaire, and the INTREX Introject Questionnaire. Interviewers at pre- and post-treatment and at one-year follow-up were blinded; at two-, and three-year follow-up all self-report instruments were mailed to the patients. Analyses of covariance, effect sizes and clinical significances were calculated to contrast the groups.

We found significant outcome differences between treatments in terms of depressive and global psychiatric symptoms, personality functioning and social relations at three-year follow-up with psychoanalytic therapy being significantly more effective. No outcome differences were found in terms of interpersonal problems.

We concluded that psychoanalytic therapy with its higher dose and frequency and different therapeutic technique shows longer-lasting effects than psychodynamic therapy, demonstrating the full range of its benefits three years after termination of treatment.

Contact

Professor Dorothea Huber, M.D., Ph.D.

International Psychoanalytic University (IPU), Stromstrasse 3b, 10555 Berlin, Germany.

Klinik für Psychosomatische Medizin und Psychotherapie, Klinikum München, Sanatoriumsplatz 2, 81545 München.

Munich Psychotherapy Study (MPS) – A three-year follow-up study: Comparison of cognitive-behavioral therapy with psychoanalytic and psychodynamic therapy for depressed patients

Huber, D., Zimmermann, J., Henrich, G., & Klug, G. (2012). Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients – A three-year follow-up study. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 58: 299–316.

Huber, D., Henrich, G., Gastner, J., & Klug, G. (2012). The Munich Psychotherapy Study: Must all have prizes? In R. Levy, S. Ablon & H. Kächele (Eds.), Psychodynamic Psychotherapy Research. Evidence-Based Practice and Practice-Based Evidence (pp. 51-69). Totowa, NJ: Humana Press.

Brief Summary

In an extension of the above mentioned study we additionally investigated the effectiveness of long-term cognitive-behavioral therapy compared to psychoanalytic and psychodynamic therapy in the treatment of patients with depression. Therefore, in a quasi-experimental design 100 patients were compared at pre- and post-treatment and at three-year follow-up. Outcome measures see above.

We found significant outcome differences between psychoanalytic therapy and cognitive-behavioral therapy in depressive and global psychiatric symptoms, social-interpersonal and personality structure at three-year follow-up. Psychodynamic therapy was superior to cognitive-behavioral therapy only in the reduction of interpersonal problems.

We conclude that psychoanalytic (and partly psychodynamic) therapy shows significantly higher and longer-lasting effects compared to cognitive-behavioral therapy three years after termination of treatment.

Evaluation

This study moves in the middle of the pragmatic-explanatory continuum, having significant scientific strengths as well as the potential capacity to inform healthcare decision-making regarding clinical practice; thus it can be rubricated as a pragmatic or practical clinical trial.

Our study has several limitations as well, as the small sample sizes and the lack of a Structured Clinical Interview for DSM-IV (SCID-I and SCID-II) assessment of primary and co-morbid diagnoses.

In terms of internal validity, the differing dose of the treatments (i.e., the number of sessions) can be considered to be a confounder. We believe that each treatment has a different underlying working model that needs a specified time frame with a stipulated number of sessions and specific interventions in order to initiate a specific process. Moreover, we deliberately wanted to investigate treatment packages with their prototypical doses to inform practitioners about their everyday practice, thus helping to bridge the notorious gap between research and practice.

This study should enlarge our empirically based knowledge of the enduring effects of long-term psychotherapies, especially psychoanalytic therapy.

Contact

Professor Dorothea Huber, M.D., Ph.D.

International Psychoanalytic University (IPU), Stromstrasse 3b, 10555 Berlin, Germany.

Klinik für Psychosomatische Medizin, Klinikum München, Sanatoriumsplatz 2, 81545 München.

Email:dorothea.huber@ipu-berlin.de

Helsinki Psychotherapy Study

Knekt P, Laaksonen MA, Härkänen T, Maljanen T, Heinonen E, Virtala E, Lindfors O. The Helsinki Psychotherapy Study: effectiveness, sufficiency, and suitability of short- and long-term psychotherapy. In: Levy R, Ablon JS, Kächele H (eds.) Psychodynamic Psychotherapy Research. Evidence-Based Practice and Practice-Based Evidence, Humana Press, 2012; 71-94.

Knekt P,  Lindfors O, Härkänen T, Välikoski M, Virtala E, Laaksonen MA, Marttunen M, Kaipainen M, Renlund C and the Helsinki Psychotherapy Study Group. Randomized trial on the effectiveness of long- and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychol Med 2008; 38: 689–703.

 

Knekt P, Lindfors O, Renlund C, Sares-Jäske L, Laaksonen MA, Virtala E. Use of auxiliary psychiatric treatment during a 5-year follow-up among patients receiving short- or long-term psychotherapy. J Aff Disord 2011a; 135: 221-230.

 

Knekt P, Lindfors O, Laaksonen MA, Renlund C, Haaramo C, Härkänen T, Virtala E, and the Helsinki Psychotherapy Study Group. Quasi-experimental study on the effectiveness of psychoanalysis, long-term and short-term psychotherapy on psychiatric symptoms, work ability and functional capacity during a 5-year follow-up. J Aff Disord 2011b; 132: 37- 47.

 

Lindfors O, Knekt P, Virtala E, Laaksonen MA, the Helsinki Psychotherapy Study Group. The effectiveness of solution-focused therapy and short- and long-term psychodynamic psychotherapy on self-concept during a 3-year follow-up. J Nerv Ment Dis 2012; 200: 946-953.

Brief Summary

The aims of this ongoing study are to evaluate the effectiveness of two long-term and two short-term psychotherapies and the prediction of patient and therapist factors on the alliance and the outcome of short- vs long-term therapy (Knekt et al. 2012). Both quantitative and qualitative methods are used to meet these aims. Methodological research in the areas of development and implementation of statistical methods for evaluation of the effectiveness and efficacy and of measurement instruments is included. Two separate designs are used for the effectiveness study. In a randomized design, patients were assigned to one of three treatment groups: solution-focused therapy, short-term psychodynamic psychotherapy, and long-term psychodynamic psychotherapy. In a quasi-experimental design, patients who were randomly assigned to the psychotherapies are compared to patients who were self-selected for psychoanalysis. The prediction study is based on a cohort design. The participants are 367 outpatients from psychiatric services in the Helsinki region having long-standing depressive or anxiety disorder causing work dysfunction. Patients with psychotic disorder, severe personality disorder, adjustment disorder, bipolar disorder or substance abuse were excluded. The outcome assessment covers different measures of psychiatric symptoms and recovery (Knekt et al. 2008), need for treatment (Knekt et al. 2011a), work ability (Knekt et al. 2011b), personality functioning (Lindfors et al. 2012), social functioning, lifestyle, and cost-effectiveness. These outcome measures are administered longitudinally: prior to start of treatment and at 14 pre-chosen time points during a 10-follow-up from start of treatment. Solution-focused therapy included 12 and short-term psychodynamic psychotherapy 20 therapy sessions, both therapies lasting about half a year. The long-term therapies were open-ended, psychodynamic psychotherapy lasting about 3years with about 240 sessions and psychoanalysis lasting about 5 years and about 650 sessions. Only solution-focused therapy was manualized whereas the psychodynamic therapies were conducted in accordance with clinical practice, where the therapists might modify their interventions according to the patient’s needs within the respective framework. All the therapists had received standard training and were experienced: the mean number of years of work experience was 9 in the short-term and over 15 years in the long-term therapies.

About 60 peer reviewed original contributions have been published from this study within the areas of effectiveness, suitability, therapist factors, alliance, measurement methods, statistical methods, and qualitative research. A number of current sub-studies within these areas are ongoing (see cited literature above and our homepage).

Evaluation

This study assesses the effectiveness of short-term vs long-term therapy during a very long time period from start of treatment. It also gives criteria, based on multiple patient perspectives, for whom long-term therapy seems necessary and who may recover by short-term therapy. The importance of auxiliary treatment in the evaluation of the sufficiency of treatment is introduced as a key element of outcome. The role of the therapeutic alliance in the prediction and mediation of the change processes will also be possible. The findings can thus be applied in clinical practice. The study will also give information on which therapist factors are suitable for long-term and which for short-term therapy and can thus be taken into account in therapist training. Limitations include the absence of a control group and manualization of the psychodynamic therapies.

Contact Address for Study

Dr. Paul Knekt, National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki, Email: paul.knekt@thl.fi Website: www.thl.fi/hps


 

Patient predictors of psychotherapy outcome in the Helsinki Study

Laaksonen, M., Knekt, P., & Lindfors, O. (2013). Psychological predictors of the recovery from mood or anxiety disorder in short-term and long-term psychotherapy during a 3-year follow-up. Psychiatry Research, 208, 162-173.
Laaksonen, MA, Sirkiä C, Knekt P, Lindfors O. (2014). Self-reported immature defense style as a predictor of outcome in short- and long-term psychotherapy. Brain and Behavior. Open Access, Doi:10.1002/brb3.190.
Lindfors, O., Knekt, P., Heinonen, E., & Virtala, E. (2014a). Self-concept and quality of object relations as predictors of suitability for short- and longterm psychotherapy. Journal of Affective Disorders, 152-154, 202-211.
Lindfors, O., Ojanen, S., Jääskeläinen, T., & Knekt, P. (2014b). Social support as a predictor of the outcome of depression and anxiety disorder in short-term and long-term psychotherapy. Psychiatry Research, 216, 44-51.
Joutsenniemi, K., Laaksonen, M., Knekt, P., Haaramo, P., & Lindfors, O. (2012). Prediction of socio-demographic factors on the outcome of short- and long-term psychotherapy. Journal of Affective Disorders, 141, 331-342.

Brief Summary

The aims of this ongoing study are to evaluate the prediction of patient factors on the alliance and the outcome of short-, long-, and short- vs long-term therapy (Knekt et al. 2012). The prediction study is based on a cohort design and the data is coming from the Helsinki Psychotherapy Study. The participants are 367 outpatients from psychiatric services in the Helsinki region having long-standing depressive or anxiety disorder causing work dysfunction. Patients with psychotic disorder, severe personality disorder, adjustment disorder, bipolar disorder or substance abuse were excluded. Solution-focused therapy included 12 and short-term psychodynamic psychotherapy 20 therapy sessions, both therapies lasting about half a year. The long-term therapies were open-ended, psychodynamic psychotherapy lasting about 3years with about 240 sessions and psychoanalysis lasting about 5 years and about 650 sessions. All the therapists had received standard training and were experienced. The outcome assessment covers different measures of psychiatric symptoms and recovery, need for treatment, work ability, personality functioning, social functioning, lifestyle, and cost-effectiveness. These outcome measures are administered longitudinally: prior to start of treatment and at 14 pre-chosen time points during a 10-follow-up from start of treatment. The predictors, mainly determined at baseline, included patients’ psychiatric symptoms, psychological functioning, social functioning, and genetic factors (i.e. DNA determined from blood samples). The main focus of the study is the search for evidence-based criteria to be used in choosing an appropriate treatment for a patient. An interview-based pre-treatment suitability assessment measure of patient’s personality characteristics and interpersonal dispositions has been developed and found to be useful in the selection of short- or long-term psychotherapy (Laaksonen et al. 2012, 2013). Several other patient factors, assessed by interview or questionnaires, have also emerged as potential predictors of prognosis in different therapies. Further study will extend the scope of the predictors of suitability and will evaluate the relative importance of them.

Several original contributions have been published from this sub-study (Joutsenniemi et al. 2012, Laaksonen et al. 2014, Lindfors et al. 2014a, 2014b), and a number of studies are ongoing (see cited literature above and our homepage).

Evaluation

This study gives criteria, based on multiple patient perspectives, for whom long-term therapy seems necessary and who may recover by short-term therapy. The role of the therapeutic alliance in the prediction and mediation of the change processes will also be possible. The findings can thus be applied in clinical practice. Limitations include the number of patients and possible residual confounding despite adjustement for potential confounding factors.

Contact

Dr. Paul Knekt

National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki

Email: paul.knekt@thl.fi

Website: www.thl.fi/hps

The effects of scheduled waiting for psychotherapy of depression

Ahola, P., Joensuu, M., Knekt, P., Lindfors, O., Saarinen, P.I., Tolmunen, T., Valkonen-Korhonen, M., Jääskeläinen, T., Virtala, E., Tiihonen, J., Lehtonen, J. A manuscript in submission.

Method

33 outpatients with major depressive disorder were randomly selected to start dynamic psychotherapy (twice a week) directly (DG, n = 17) and after waiting for six months (WG, n = 16). The symptoms were assessed using the HAMD-17, BDI, SCL-90-DEP, SCL-90-ANX, SCL-90-GSI and TAS-20 before and after waiting, and before and after 12 months of psychotherapy.

Results

It was found that depressive symptoms declined significantly among the subjects during the waiting time and among those directly receiving psychotherapy without significant group differences. After 12 months of psychotherapy, a significantly stronger decline in anxiety was found in WG patients. Other outcome differences were not found and both groups showed significant symptom remission.

Conclusions

We conclude that scheduled waiting for psychotherapy is clinically safe and associates with a significant decline in symptoms. We regard it likely that the scheduled protocol for the waiting time is perceived as a preparatory phase for treatment, which already has a significant effect on symptoms even though active treatment has not yet taken place. We furthermore suggest that this hope rising effect may be included in the initial stage of any scheduled treatment and its nonspecific effect should be recognised.

Contact

Dr. Paul Knekt

National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki

Email: paul.knekt@thl.fi

Website: www.thl.fi/hps

Mentalisation-based treatment of BPD

Bateman, A. W., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder. Mentalisation-based treatment. Oxford: Oxford University Press.

Bateman, A. W., & Fonagy, P. (2004). Mentalisation-based treatment of BPD. Journal of Personality Disorder, 18(1), 36-51.

Bateman, A. W., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165(5), 631-638.

Objective

This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.

Method

Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables.

Results

Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.

Conclusions

Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

Contact

Prof. Antony Bateman

Consultant Psychiatrist in Psychotherapy, Barnet Enfield and Haringey Mental Health NHS Trust, Halliwick Psychological Therapies Service, St Ann's Hospital, St Ann's Road, London.

E-mail: anthony@mullins.plus.com

The LAC Depressionstudy

Authors

Marianne Leuzinger-Bohleber, Martin Hautzinger

Manfred Beutel ,Ulrich Bahrke, George Fiedler, Wolfram Keller, Lisa Kallenbach, Margerete Schoett, Johannes Kaufhold, Alexa Negele, Bernhard Rüger

 References: 

Beutel, M.E.; Leuzinger-Bohleber, M.; Rüger, B.; Bahrke, U.; Negele, A.; Haselbacher, A.; Fiedler, G.; Keller, W.; Hautzinger, M. (2012): Psychoanalytic and cognitive-behavior therapy of chronic depression: study protocol for a randomized controlled trial. Trials (2012) 13:117 open acces

http://www.trialsjournal.com/content/pdf/1745-6215-13-117.pdf

Leuzinger-Bohleber, M. (2015): Working with severely traumatized, chronically depressed analysands. In: The International Journal of Psychoanalysis Volume 96, Issue 3, June 2015, Pages: 611–636

Leuzinger-Bohleber, M.,Hautzinger, M., Fiedler, G., Keller, W., Bahrke, U., Kallenbach, L., Kaufhold, J., Ernst, M., Negele, A., Schoett, M. Küchenhoff, H., Günther, F., Rüger, B., Beutel, M. (2018): Outcome of Psychoanalytic and Cognitive-Behavioral Long-term-Therapy with Chronically Depressed  Patients.  A controlled trial with preferential and randomized allocation: The Canadian Journal of Psychiatry /DOI: 10.1177/0706743718780340

Leuzinger-Bohleber, M., Kaufhold, J., Kallenbach, L., Negele, A., Ernst, M., Keller, W., Fiedler, G., Hautzinger, M., Beutel, M. (in press): Does sustained symptomatic improvement of chronically depressed patients need structural change in long-term psychotherapies? Findings from the LAC depression study comparing the outcomes of cognitive-behavioral and psychoanalytic long-term treatments. Int. J Psychoanal., (will be published in February 2019)

Leuzinger-Bohleber, M.,Hautzinger, M., Fiedler, G., Keller, W., Bahrke, U., Kallenbach, L., Kaufhold, J.,  Negele, A., Schoett, M. Küchenhoff, H., Günther, F., Rüger, B., Ernst, M., Rachel, P. Beutel, M. (2019): Psychoanalytische und kognitiv-behavioraleLangzeitbehandlung chronisch depressiver Patienten bei randomisierter oder präferierter Zuweisung. Ergebnisse der LAC-Studie. Psyche – Z Psychoanal 73, 2019, 0000–0000. DOI 10.21706/ps-72-2-0000

Kaufhold, J., Bahrke, U. Kallenbach, L., Negele, A., Ernst, M., Keller, W.,Rachel, P. Fiedler, G., M..Hautzinger, M.,Leuzinger-Bohleber, M. Beutel, M. (2019): Wie können nachhaltige Veränderungen in Langzeittherapien untersucht werden? Symptomatische versus strukturelle Veränderungen in der LAC-Depressionsstudie.Psyche – Z Psychoanal 73, 2019, 0000–0000. DOI 10.21706/ps-72-2-0000

The rationale or purpose of the study: 

While a large number of studies on the results of short-term psychoanalytic therapies are now available, such studies on psychoanalysis and long-term psychoanalytic therapies are still largely lacking. However, it is part of clinical experience that special groups of patients, e.g. chronic depressed individuals, hardly achieve a sustaining improvement of their mental condition in short-term treatments and therefore need longer treatments. Therefore, in 2005, al large research group in Germany decided to compare the results of psychoanalytic (PAT) and cognitive-behavioral (CBT) long-term therapies in chronic depressive patients in a large multicenter study, the so-called LAC study.

The multicentric large LAC study was started in 2005. First results have been published after 3 years of treatment (see above). The study is still ongoing: The outcomes after 5 years of treatment are analysed at the moment. The study was supported by the DGPT (the head organization of all psychoanalytical schools in Germany, the Heidehof Foundation, the German Research Foundation (DFG), the IPA, Dr. M. Tann and other private donators.

The approach or method taken: 

Patients were assigned to treatment according to their preference or randomized (if they have no preference). Up to 80 sessions of psychodynamic or psychoanalytically oriented treatments (PAT) or up to 60 sessions of CBT were offered during the first year in the study. After the first year, PAT could be continued according

to the ‘naturalistic’ usual method of treating such patients within the system of German health care (normally from 240 up to 300 sessions over two to three years). CBT therapists could extend their treatment up to 80 sessions, but focused mainly on maintenance and relapse prevention. A total of 11 assessments were conducted throughout treatment and up to five years after initiation of treatment.

We were using several interviews (psychoanalytical initial interviews, SKID I,II, OPD Interviews (Operationalized Psychodynamic Diagnostics), HUS (Heidelberger Umstruktuierungs Skala), SRS (Selfreflecting Scales), LIFE Interview and a broad spectrum of questionnaires (BI, QIDS, HAQ,DEQ,DAS,SOFAS,CTQ, IIP, SCL-90-R. as well as mental health data. We also have carefully documented clinical data as well fMRI/EEG-Data (FRED Study, Frankfurt) from a subsample of the patients.

We have recruited a total of 554 patients. A total of 252 adults met the inclusion criteria (age 21 - 60 years, major depression, dysthymia, double depression for at least 24 months, QIDS>9, BDI>17, informed consent, not meeting exclusion criteria).

Main outcome measures were depression self-rating (BDI) and rating (QIDS-C) by independent, treatment blinded clinicians. Full remission rates (BDI ≤ 12, QIDS-C ≤ 5) were calculated.

An independent center for data management and bio-statistics analyzed the treatment effects and differences using linear mixed models (multilevel models and hierarchical models).

The central findings: 

A)   Concerning main outcome criteria: The average BDI declined from 32.1 points by 12.1 points over the first year, and 17.2 points over three years. BDI overall mean effect sizes increased from d = 1.17 after one year to d = 1.83 after three years. BDI remission rates increased from 34% after one year to 45 % after three years. QIDS-C overall effect sizes increased from d = 1.56 to d = 2.08, and remission rates rose from 39% after one year to 61% after three years. We found no significant differences between PAT and CBT or between preferential and randomized allocation.  (see Leuzinger-Bohleber et al, 2018)

B)   Concerning symptomatic versus structural change: It is well known that psychoanalytical treatments do not focus exclusively on the reduction of psychopathological symptoms, but rather to changes in the in the inner world of the patients, so-called "structural changes". Therefore we published a second outcome paper on the results of changes associated with the Operationalized Psychodynamic Diagnostics (OPD)  in order to investigate so called “structural changes”. Three years after onset of the treatments showed more patients in psychoanalytic treatments structural changes than in cognitive-behavioral treatments. In addition these structural changes in PAT were more pronounced than in CBT Influence on symptom change.

The implication of the results:

Psychoanalytic as well as cognitive behavioral long-term treatments lead to significant and sustained improvements of depressive symptoms of chronically depressed patients (high effect sizes, high complete rates of remission). Since PAT needs more sessions than CBT to achieve analogue symptom improvements, it has been shown that there are differences between the different therapies and their results if the research microscope is adjusted differently. If, for example, the structural changes are investigated with the help of OPD, it can be seen that statistically such changes occur more frequently in the PAT group.

Currently, the direct and indirect costs of the two treatments, as well as the use of medication, are being studied using the data to address the argument that PAT is more expensive than CBT. Several studies have shown that this is not so clear once the indirect costs of long-term mute therapies are also included.

Contact:

Marianne Leuzinger-Bohleber m.leuzinger-bohleber@sigmund-freud-institut.de

hautzinger@uni-tuebingen.de

Manfred.Beutel@unimedizin-mainz.de

Wolfram Keller wkel@hotmail.de

g-fiedler@t-online.de

 

 

The INDDEP study: inpatient and day hospital treatment for depression – symptom course and predictor of change

Zeeck, A., von Wietersheim, J., Weiss, H., Beutel, M., Hartmann S. (2013) : The INDDEP study: inpatient and day hospital treatment for depression- symptom course and predictor of change. BMC Psychiatry, 13, 100.

Background

Depression can be treated in an outpatient, inpatient or day hospital setting. In the German health care system, episodes of inpatient or day hospital treatment are common, but there is a lack of studies evaluating effectiveness in routine care and subgroups of patients with a good or insufficient treatment response. Our study aims at identifying prognostic and prescriptive outcome predictors as well as comparative effectiveness in psychosomatic inpatient and day hospital treatment in depression.

Methods / Design

In an naturalistic study, 300 consecutive inpatient and 300 day hospital treatment episodes in seven psychosomatic hospitals in Germany were included. Patients are assessed at four time points of measurement (admission, discharge, 3-months follow-up) including a broad range of variables (self-report and expert ratings). First, the whole sample will be analysed to identify prognostic and prescriptive extert rating). Secondly. For a comparison of inpatient and day hospital treatment, samples will will be matched according to known predictors of outcome.

Discussion

Naturalistic studies with good external validity are needed to assess treatment outcome in depression in routine care and to identify subgroups of patients with different therapeutic needs.

Contact

Prof. Dr. Heinz Weiss

Robert Bosch Krankenhaus, Stuttgart

Email: Heinz.Weiss@rbk.de

Psychodynamic interpersonal therapy (PIT) for patients with multi-somatoform disorders (PISO)

Sattel, H., Lahmann, C., Gündel, H., Guthrie, E., Kruse, J., Noll-Hussong, M. . . . Henningsen, P. (2012). Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial. British Journal of Psychiatry, 200(1), 60-67.
Sattel, H., Kittner, A., & Henningsen, P. (2011). Eine psychodynamisch-interpersonelle Kurztherapie für Patienten mit multisomatoformen Störung (PISO) - Passt dies für alle? {A brief psychodynamic-interpersonal psychotherapy for patients with multisomatoform disorder (PISO) – one size fits all?} Psychotherapie Psychosomatik medizinische Psychologie, 61, A070.
Otti, A., Gündel, H., Henningsen, P., Zimmer, C., Wohlschlaeger, A., & Noll-Hussong, M. (2013). Functional network connectivity of pain-related resting state networks in somatoform pain disorder: an exploratory fMRI study. Journal of Psychiatry and Neuroscience, 38(1), 57-65.

Brief Summary

In 2006 a group of researchers with a psychodynamic background (“PISO working group”) started after thorough preparation a large multicenter randomized clinical trial. The study was supported by the German Research Foundation DFG.

Background

Patients with distressing bodily symptoms – in particular when these cannot be sufficiently explained by organic causes – are common in the healthcare system. Although many of these patients are not satisfied with the delivered medical treatment they remain to be heavy users of healthcare, thus incurring large costs to health services and society. Although there is some evidence that psychotherapy is a promising option for this disorder, trials studying cognitive–behavioural therapy (CBT) and short-term psychodynamic therapies have been of less than adequate size or did not address the full diagnostic range of these disorders.

Methods

We conducted our study at six university departments of psychosomatic medicine, were we recruited 211 patients from the out-patient departments of neurology and internal medicine, from pain treatment centres and an orthopaedics private practice. The included patients required to have a minimum of three current somatoform symptoms (pain, dizziness, bowel dysfunction, fatigue, etc.) that are functionally disabling and that an organic disease or another mental disorder cannot sufficiently explain plus a history of somatoform symptoms on at least half of the days over at least 2 years, resulting in healthcare use. These were established by the somatoform disorders and hypochondria sections of the Structured Clinical Interview for DSM-IV (SCID). The data storage and monitoring as well as the statistical analysis of the primary outcome was executed by an independent clinical study coordination centre, following high methodological standards.

The dimensions assessed in our study covered self-report data on physical and mental quality of life, psychopathology (depression, somatization, (health-) anxiety), illness perception, health care use, attachment styles, alexithymia and an evaluation of the therapeutic process. The assessments were made before and after treatment, plus a follow up, which  was carried out 9 months after end of therapy. Additionally heart rate variability was measured as an indicator for organismic adaptability.

Treatment

Psychodynamic interpersonal therapy (PIT) consisted of 12 weekly sessions, which were specifically adapted to the needs of patients with bodily distress. Conceptually, our approach assumes that developmentally based dysregulations of (bodily) self-experience and relationships rather than unconscious conflicts are the primary basis for the symptoms. PIT was compared with an Enhanced Medical Care group, which received education and counselling regarding the therapeutic alternatives based on the evidence-based guidelines for the treatment of somatoform disorders/functional somatic syndromes in primary and somatic specialist care. Both treatments were manualized and the adherence of the therapists was determined for all therapeutic sessions.

Results

As primary outcome we prespecified a clinically relevant improvement in bodily quality of life (as compared to the control group). Our findings suggest that this improvement can be achieved using a short-term intervention consisting of 12 PIT sessions in patients, who experience chronic and disabling bodily symptoms that have no recognised treatment. The success of the treatment was independent of the patients’ bodily symptom characteristics of each patient, so that PIT was suited to improve bodily quality of life in patients with a multitude of different chronic physical symptoms.

So far additional analyses related to our study addressed economic aspects of PISO, attachment styles, functional MR-imaging studies and the use of heart rate variability in order to predict therapy outcome. These studies are published or underway.

Contact

Prof. Dr. med. Peter Henningsen
Department of Psychosomatic Medicine and Psychotherapy, Klinikum Rechts der Isar, Technische Universität München
Langerstr. 3
D-81675 Munich

Email: p.henningsen@tum.de

The efficacy of a psychoanalytic psychotherapy for panic disorders: Panic-Focused Psychodynamic Psychotherapy (PFPP)

Busch, F. N.; Milrod, B. L.; & Sandberg, L. S. (2009). A study demonstrating efficacy of a psychoanalytic psychotherapy for panic disorder: implications for psychoanalytic research, theory and practice. Journal of the American Psychoanalytic Association, 57 (1): 131-48.
Milrod, B. L.; Cooper, A.; & Shapiro, T. (1997). Manual of Panic-Focused Psychodynamic Psychotherapy. Washington, DC: American Psychiatric Press.
Milrod, B. L.; Leon, A. C.; Busch, F. N.; Rudden, M.; Schwalberg, M.; Clarkin, J.; Aronson, A.; Singer, M.; Turchin, W.; Klass, E. T.; Graf, E.; Teres, J. J.; & Shear, M. K. (2007). A randomized controlled clinical trial of psycho­analytic psychotherapy for panic disorder. American Journal of Psychiatry, 164, 265–272.

Brief Summary

Systematic research on psychoanalytic treatments has been limited by several factors, including a belief that clinical experience can demonstrate the effectiveness of psychoanalysis, rendering systematic research unnecessary, the view that psychoanalytic research would be difficult or impossible to accomplish, and a concern that research would distort the treatment being delivered. In recent years, however, many psychoanalysts have recognized the necessity of research in order to obtain a more balanced assessment of the role of psychodynamic psychotherapy and psychoanalysis in a contemporary treatment armamentarium, as well as to allow appropriate evaluation and potentially greater acceptance by the broader mental health and medical communities. In this context, studies were performed on psychodynamic treatment, Panic-Focused Psychodynamic Psychotherapy (PFPP), initially in an open trial and then in a randomized controlled trial (RCT) in comparison with a less active treatment, Applied Relaxation Training (ART), for adults with primary DSM-IV panic disorder.

The PFPP studies were conducted from 1997 to 2005 at Weill Cornell Medical College, using therapists who were Ph.D. psychologists or M.D.s after psychiatric residency, all of whom completed at least three years of psychoanalytic training in New York City area APsaA-approved psychoanalytic training programs. All study therapists were trained on how to conduct PFPP in accord with the treatment manual. Initial cases were closely supervised. The PFPP manual (Milrod, Cooper, and Shapiro 1997) was constructed around a psychodynamic formulation of panic disorder, which incorporated the work of psychoanalytic theorists and clinicans as well information derived from psychological studies of patients with panic disorder—e.g., parental perceptions, premorbid personality traits, defense mechanisms. Based on these clinical observations and studies, a formu­lation was developed that outlines a series of dynamics central to panic disorder (Milrod et al., 1997), including ambivalence about autonomy and dependency, fear of anger disrupting needed attachments, narcissistic humiliation surrounding panic, ego deficiencies, and sexual conflicts (find detailed information about the therapeutical focus of the PFPP manual in Milrod et al., 1997). After the first draft of the manual was formulated, it was given to four psychoanalysts, all experts in treating anxiety, who had not been involved in its creation, for comment in an effort to ensure that the manual captured the way psychoanalysts in fact treat patients with panic disorder. All four felt the manual closely approximated their own psychoanalytic clinical work, suggesting that operationalizing these approaches need not create a rigid or nonpsychoanalytic treatment.

The open clinical trial of PFPP was initially accomplished between 1997 and 2000 and was not an efficacy study, as there was no comparison condition, but was designed to determine whether PFPP could be reliably delivered, and to assess its effects on patients with panic disorder. Twenty-one patients with primary DSM-IV panic disorder signed informed written consent forms and were treated with twenty-four sessions of PFPP over twelve weeks. No concurrent treatments were permitted during this clinical trial, and patients who presented on ineffective anti-panic medications (i.e., who met symptomatic study entrance criteria while taking pharmacological agents) were tapered off of their medica­tion regimens in order to gain access to the study. Four patients dropped out, and at termination sixteen of the remaining seventeen met “response” criteria, a greater than 40 percent reduction in the Panic Disorder Severity Scale (PDSS). In addition to a significant reduction in symptoms of panic disorder, the patients demon­strated significant improvement in measures of psychosocial function, anxiety unrelated to panic, and depression. Notably, comorbid major depression, present in eight of twenty-one patients, remitted with PFPP as well. Clinical improvements were maintained at six-month follow-up, without intervening treatment.

Following the open trial, our group proceeded with a randomized controlled trial (Milrod et al. 2007) in which PFPP was compared with a less active psychotherapy, applied relaxation training (ART), to assess efficacy. ART was chosen as a comparison therapy because it has been shown to be a credible and efficacious treatment for panic disorder. In the efficacy study, treatments were designed to match in number and frequency of sessions and in the degree of therapist experience, making this treatment trial a conservative one, less likely to show differences between treatment conditions. Nonetheless, a significantly greater reduction in a broad range of panic symptoms was observed after PFPP, compared with ART, as assessed by the Panic Disorder Severity Scale, the primary outcome measure. Using the a priori definition of “response”, PFPP demonstrated a significantly higher rate of response com­pared with ART: 73% vs. 39% (p = .017). PFPP also led to significantly greater improvement in psychosocial function, as measured on the Sheehan Disability Scale (SDS): p = .014. The SDS is a self-report instrument using a visual analog scale in which the patient rates himself from 0 (not at all impaired) to 10 (extremely impaired) by symptoms in each of three areas: work or school, social life, and family life/home responsibilities. In addition, the PFPP studies assessed adherence with a well-operationalized scale demonstrated excellent interrater reliability (ICC [intraclass correlation coefficient] = .92), indicating that independent rat­ers assessing the same sessions or therapeutic treatment obtain very similar results. Most of the study therapists have easily met adherence standards (Milrod et al. 2007).

Evaluation

The PFPP efficacy study is part of a small but increasing effort to intro­duce psychoanalytic psychotherapy into the era of evidence-based medi­cine, in that it is the first psychoanalytic psychotherapy for a primary DSM-IV Axis I anxiety disorder to have demonstrated efficacy. We can expect that nonpsychoanalytic colleagues, and institutions that monitor clinical practice (the American Psychiatric Association, the Institute of Medicine, the National Institute for Health and Clinical Excellence in the UK), will show a new respect for psychoanalytic psychotherapy for panic disorder. This study should give pause to those within our own ranks who maintain that psychoanalysis and psychoanalytic psychotherapy cannot be empirically studied.

Contact

Prof. Fredric N. Busch,

Weill Cornell Medical College

Columbia Center for Psychoanalytic Training and Research.

Email: fnb80@aol.com

Website: www.weill.cornell.edu

The Personality Disorders Institute (PDI) of the Weill Cornell Medical College

Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2004). The Personality Disorders Institute / Borderline Personality Disorder Research Foundation randomized control trial for borderline personality disorder: Rationale, methods, and patient characteristics. Journal of Personality Disorders, 18(1): 52-72.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164, 922-928.
Clarkin, J. F., & Levy, K. N. (in press). Empirical status of Transference Focused Psychotherapy. Psychoanalytic Inquiry.

The Personality Disorders Institute (PDI) of the Weill Cornell Medical College, under the leadership of Otto F. Kernberg and John F. Clarkin, has the goal of investigating personality pathology, and developing empirically a psychodynamic treatment for these disorders. The empirical investigations of the PDI are guided by object relations theory which posits the centrality of internalized representations of self and other, and related affects in both the pathology and a central focus of therapeutic change (Kernberg, 1984; Kernberg, 2012; Kernberg & Caligor, 2005).

Groundwork

In order to empirically investigate complex and clinically relevant object relations concepts, a self-report inventory and a semi-structured interview have been developed. The Inventory of Personality Organization (IPO) is a self-report instrument that measures the constructs of identity diffusion, primitive defenses, reality testing, aggression, and moral values (Lenzenweger, Clarkin, Kernberg, & Foelsch, 2001). The object relations constructs in the IPO have significant associations with other key personality traits (Lenzenweger, McClough, Clarkin, & Kernberg, 2012). The Structured Interview of Personality Organization (STIPO) is a semi-structured interview which reliably assesses patients’ identity, defenses, quality of object relations, coping strategies, aggression, and moral values (Stern, Caligor, Clarkin, Critchfield, Horz, MacCornack, Lenzenweger, & Kernberg, 2010).  The STIPO has been used to demonstrate personality organization changes following a dynamic treatment (Doering, et al, 2010).

We have done extensive empirical work examining the nature of borderline personality disorder (BPD). We examined the criteria for BPD diagnosis by factor analysis (Clarkin, Hull, & Hurt, 1993), and found three factors in the condition: identity diffusion, affective dysregulation, and impulsivity.  By using object relations theory combined with finite mixture modeling, we have isolated three groups of borderline individuals (Lenzenweger, Clarkin, Yeomans, Kernberg, & Levy, 2008). These three groups vary not only in terms of severity but also in terms of combination of adjustments to aggression, paranoid ideation, and antisocial traits. Aggression in BPD patients is influenced by the patients’ attachment style (Critchfield, Levy, Clarkin, & Kernberg, 2008). In a cross-cultural study with colleagues in Germany, we have used the Adult Attachment Interview (AAI) to examine attachment and mentalization in patients with co-occurring BPD and narcissistic personality disorder (Diamond, Levy, Clarkin, Fischer-Kern, Cain, Doering, Hörz, & Buchheim, in press).

Manualisation

An object relations treatment for personality disorders has been detailed in two treatment manuals.  Transference-focused psychotherapy (TFP) has been described for patients with BPD and borderline personality organization (Clarkin, Yeomans, & Kernberg, 2006). In addition, a version of this psychodynamic treatment has also been described for patients with higher level personality pathology (Caligor, Clarkin, & Kernberg, 2007).

Experiment

TFP for patients with borderline personality disorder has been empirically examined and supported in two randomized clinical trials, one in New York City (Clarkin, Levy, Lenzenweger, & Kernberg, 2007), and one in Europe (Doering, Hörz, Rentrop, Fischer-Kern, Schuster, Benecke, Buchheim, Martius, & Buchheim, 2010). In addition to symptom reduction, TFP resulted in an increase in narrative coherence and reflective functioning (Levy, Meehan, Kelly, Reynoso, Weber, Clarkin, & Kernberg, 2006), and improvement in personality organization (Doering, Hörz, Rentrop, Fischer-Kern, Schuster, Benecke, Buchheim, Martius, & Buchheim, 2010).  We have isolated predictors of change and rates of change in the treatment of BPD patients (Lenzenweger, Clarkin, Levy, Yeomans, & Kernberg, 2012).

Perspectives

Our current work builds on these previous findings. We are in the process of using pre-treatment genetic markers combined with neurocognitive functioning (fMRI) to predict response to TFP over a treatment episode of 18 months. A major goal of the extended treatment is not only symptom reduction, but also significant improvement in work functioning and satisfaction in interpersonal relations.

Contact

John F. Clarkin, Ph.D.

Clinical Professor of Psychology in Psychiatry, Weill Cornell Medical College, New York Presbyterian Hospital Westchester, 21 Bloomingdale Road, White Plains, NY 10605.

E-mail: jclarkin@med.cornell.edu

The Munich–New York Collaborative Study (MNYS): The psychodynamic treatment of BPO

Diamond, D., Levy, K. N., Clarkin, J. F., Fischer-Kern, M., Cain, N. M., Doering, S., . . . Buchheim, A. (2014). Attachment and mentalization in female patients with comorbid narcissistic and borderline personality isorder. Personality Disorders: Theory, Research, and Treatment, 5(4), 428-433.

The Department of Psychosomatic Medicine and Psychotherapy at the Technical University of Munich and the Personality Disorders Institute of the Cornell Medical Center in New York have collaborated since 1997 in conducting an empirically supported training of psycho­analytic therapists (in Munich). They have also collaborated in designing a controlled, com­pa­rative psychodynamic treatment study of German outpatients with Borderline Personality Disorders (Buchheim, P., Dammann, G., Lohmer, M., Martius, Ph. (Munich) & Kernberg, O., Clarkin, J. (New York))

Treatment

The first aim of the feasibility study is to empirically evaluate the training of a group of 30 experienced psychoanalytic therapists in the Munich centre in a particular type of object-relations treatment - “Transference focused Psychotherapy (TFP)". TFP was conceptualised and elaborated by Kernberg, Clarkin and co-workers as a manualised psychodynamic psychotherapy for patients with the diagnosis of Borderline Personality Disorder. The manual was written by the research team of the Cornell Psychotherapy Program based upon the treatment of 55 cases. Data available for this project included that from the treatment development study funded by NIMH, in which the sessions were recorded and carefully examined. This is a distillation of both the theoretical writings about the treatment and the actual experience in doing the treatment in a project explicitly designed to manualise it.

Training to adherence

The principles of the training program have been largely developed by the research team of the Cornell Psychotherapy Program over the last 17 years, with additional work over the past year in the German research group focusing on:

• the written manual describing the principles of the theory and the treatment with

accompanying clinical illustrations.

• a video-tape library of actual sessions with BPD patients, illustrating various stages of the treatment process both in terms of good adherence and relative levels of competence.

• an intensive seminar that is taught by the senior therapists to instruct new therapists in the treatment.

• the supervision of an initial case of each of the therapists in training with ratings of adherence and competence.

In Munich to date, 30 psychoanalytic therapists have applied for and were selected for the training based on their experience and reputation as excellent clinicians. Since April 1997, the German psychotherapists have been taught by Otto Kernberg, John Clarkin and Michael Stone in three intensive seminars about the principles of the theoretical and clinical concepts of the TFP-Treatment with accompanying clinical illustrations. Additionally, two very experienced German supervisors were selected by the Munich research team to receive direct training from their colleagues in the Personality Disorders Institute. The second important aim of the feasibility study, the description and evaluation of Therapy as Usual (TAU) of inpatients and outpatients with the Borderline Personality Disorders, will be conducted in collaboration with the Departments of Psychiatry of the two Medical Faculties at Munich Universities.

Evaluation

This is a major study with potentially important implications. The Munich clinic carries a particularly high caseload of patients with borderline diagnosis and therapists have considerable experience of this group of clinicians with the methodology of psychotherapy research. Additional strength is offered to the project by the international collaboration with the Cornell Group.Personality Disorders Institute, Weill Cornell Medical College: Treatment development for personality disorders

The Personality Disorders Institute (PDI) of the Weill Cornell Medical College, under the leadership of Otto F. Kernberg and John F. Clarkin, has the goal of investigating personality pathology, and developing empirically a psychodynamic treatment for these disorders. The empirical investigations of the PDI are guided by object relations theory which posits the centrality of internalized representations of self and other, and related affects in both the pathology and a central focus of therapeutic change (Kernberg, 1984; Kernberg, 2012; Kernberg & Caligor, 2005).

In order to empirically investigate complex and clinically relevant object relations concepts, a self-report inventory and a semi-structured interview have been developed. The Inventory of Personality Organization (IPO) is a self-report instrument that measures the constructs of identity diffusion, primitive defenses, reality testing, aggression, and moral values (Lenzenweger, Clarkin, Kernberg, & Foelsch, 2001). The object relations constructs in the IPO have significant associations with other key personality traits (Lenzenweger, McClough, Clarkin, & Kernberg, 2012). The Structured Interview of Personality Organization (STIPO) is a semi-structured interview which reliably assesses patients’ identity, defenses, quality of object relations, coping strategies, aggression, and moral values (Stern, Caligor, Clarkin, Critchfield, Horz, MacCornack, Lenzenweger, & Kernberg, 2010).  The STIPO has been used to demonstrate personality organization changes following a dynamic treatment (Doering, et al, 2010).

We have done extensive empirical work examining the nature of borderline personality disorder (BPD). We examined the criteria for BPD diagnosis by factor analysis (Clarkin, Hull, & Hurt, 1993), and found three factors in the condition: identity diffusion, affective dysregulation, and impulsivity.  By using object relations theory combined with finite mixture modeling, we have isolated three groups of borderline individuals (Lenzenweger, Clarkin, Yeomans, Kernberg, & Levy, 2008). These three groups vary not only in terms of severity but also in terms of combination of adjustments to aggression, paranoid ideation, and antisocial traits. Aggression in BPD patients is influenced by the patients’ attachment style (Critchfield, Levy, Clarkin, & Kernberg, 2008). In a cross-cultural study with colleagues in Germany, we have used the Adult Attachment Interview (AAI) to examine attachment and mentalization in patients with co-occurring BPD and narcissistic personality disorder (Diamond, Levy, Clarkin, Fischer-Kern, Cain, Doering, Hörz, & Buchheim, 2014).

An object relations treatment for personality disorders has been detailed in two treatment manuals.  Transference-focused psychotherapy (TFP) has been described for patients with BPD and borderline personality organization (Clarkin, Yeomans, & Kernberg, 2006). In addition, a version of this psychodynamic treatment has also been described for patients with higher level personality pathology (Caligor, Clarkin, & Kernberg, 2007).

TFP for patients with borderline personality disorder has been empirically examined and supported in two randomized clinical trials, one in New York City (Clarkin, Levy, Lenzenweger, & Kernberg, 2007), and one in Europe (Doering, Hörz, Rentrop, Fischer-Kern, Schuster, Benecke, Buchheim, Martius, & Buchheim, 2010). In addition to symptom reduction, TFP resulted in an increase in narrative coherence and reflective functioning (Levy, Meehan, Kelly, Reynoso, Weber, Clarkin, & Kernberg, 2006), and improvement in personality organization (Doering, Hörz, Rentrop, Fischer-Kern, Schuster, Benecke, Buchheim, Martius, & Buchheim, 2010).  We have isolated predictors of change and rates of change in the treatment of BPD patients (Lenzenweger, Clarkin, Levy, Yeomans, & Kernberg, 2012).

Our current work builds on these previous findings. We are in the process of using pre-treatment genetic markers combined with neurocognitive functioning (fMRI) to predict response to TFP over a treatment episode of 18 months. A major goal of the extended treatment is not only symptom reduction, but also significant improvement in work functioning and satisfaction in interpersonal relations.

Contact

John F. Clarkin, Ph.D.

Clinical Professor of Psychology in Psychiatry, Weill Cornell Medical College, New York Presbyterian Hospital Westchester, 21 Bloomingdale Road, White Plains, NY 10605.

E-mail: jclarkin@med.cornell.edu

The Vienna-Munich TFP Study: An RCT on Transference-Focused Psychotherapy vs. Treatment by Experienced Community Psychotherapists for Borderline Personality Disorder

Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., . . . Buchheim, P. (2010). Transference-focused psychotherapy v. treatment  by community psychotherapists for borderline personality disorder: randomised controlled trial. British Journal of Psychiatry, 196, 389-395.
Fischer-Kern, M., Schuster, P., ND, Tmej, A., Buchheim, A., Rentrop, M., Buchheim, P., . . . Fonagy, P. (2010). The relationship between personality organization, reflective functioning, and psychiatric classification in borderline personality disorder. Psychoanalytic Psychology, 27(4), 325-409.
Diamond, D., Yeomans, F., Levy, K., Hörz, S., Fischer-Kern, M., Delaney, J., & Clarkin, J. (2013). Transference focused psychotherapy for patients with co-morbid narcissistic and borderline personality disorder. Psychoanalytic Inquiry, 33(6), 527-555.
Diamond, D., Levy, K. N., Clarkin, J. F., Fischer-Kern, M., Cain, N., Doering, S., . . . Buchheim, A. (2014). Attachment and mentalization in patients with co-morbid narcissistic and borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 5(4), 428-433.

Brief Summary

The Munich-Vienna TFP Study was performed between 2004 and 2007. It is an RCT that compares Transference-Focused Psychotherapy (TFP) with a high quality treatment-as-usual, i.e. treatment by experienced community psychotherapists (ECP). One hundred and four female patients with borderline personality disorder (BPD) were treated for one year. TFP resulted in a significantly higher remission rate, fewer drop-outs, fewer suicide attempts, fewer psychiatric in-patient admissions, higher improvement of personality structure and psychosocial functioning. No group differences occurred with regard to self-harming behavior and self-assessment of general psychopathology.

Treatment

TFP is a manualized psychoanalytic psychotherapy for patients with borderline personality organization that was developed by Otto F. Kernberg (Clarkin et al. 2006). TFP is based on psychoanalytic object relations theory. It is a twice-per-week outpatient individual psychotherapy that combines psychodynamic principles with a structured setting and a treatment contract. The treatment focuses on the transference; once the treatment frame is in place, the core task in TFP is to identify internal object relations dyads that act as the “lenses” which determine the patient's experience of the self and the world. The aim of the treatment is to integrate split-off representations of the self and the objects and, thus, foster a maturation of personality organization.

Method

Outpatients were recruited at university hospitals in Munich and Vienna. They were randomly assigned to either TFP ior ECP. The study period covered one year, treatments were continued, if indicated. At baseline and after one year comprehensive assessments were conducted. These covered self-ratings (BDI, STAI, BSI) and interview measures (SCID-I and -II, STIPO, AAI) and observer assessments of psychosocial functioning (GAF score), self-harming behavior, and service use. Attachment style, coherence, and reflective functioning (RF) were determined from the Adult Attachment Interview (AAI).

Intent-to-treat analyses were performed in a twofold way: observed cases (OC) as well as last observation carried forward (LOCF). In addition completer analyses were conducted.

Results

In the TFP group significantly fewer drop-outs occurred (38.5% v. 67.3%) and also significantly fewer patients attempted suicide (d = 0.8, P = 0.009). TFP was significantly superior with regard to borderline symptomatology (d = 1.6, P = 0.001), psychosocial functioning (d = 1.0, P = 0.002), personality organisation (d = 1.0, P = 0.001) and psychiatric in-patient admissions (d = 0.5, P = 0.001). Both groups improved significantly in the realm of depression and anxiety and the transference-focused psychotherapy group in general psychopathology, all without significant group differences (d = 0.3–0.5). Self-harming behaviour did not change in either group. Moreover, improvement in RF was significantly greater in the TFP group as compared with the ECP group. The effect was of medium size (d = 0.45). Attachment status improved significantly in the TFP group, but not in the ECP group: Twelve out of 38 TFP patients available for follow-up changed from insecure to secure attachment status, whereas none did so in the ECP group. The coherence scale improved strongly in the TFP group (effect size d=1.27) and just moderately in the ECP group (d=0.32).

OC analyses revealed similar results as LOCF analyses with higher effect sizes and lower levels of significance. Completer analyses with control for treatment dose remained significant for GAF score, DSM-IV criteria for BPD, and personality organization.

Conclusion

TFP is an efficacious psychoanalytic psychotherapy for the treatment of patients with borderline personality organization.

Contact

Professor Stephan Doering, M.D.

Chair of the Dept. of Psychoanalysis and Psychotherapy, Medical University of Vienna

Währinger Gürtel 18-20, A-1090 Wien, Austria

Phone: +43-1-40400-25190/-30610, Fax: +43-1-406 68 03

Email: stephan.doering@meduniwien.ac.at,

Website: www.meduniwien.ac.at/hp/psychoanalyse/

Manualized Supportive-Expressive Psychotherapy Versus Nonmanualized Community-Delivered Psychodynamic Therapy for patients with personality disorders: Bridging efficacy and effectiveness

Vinnars, B., Barber, J.P., Norén, K., Gallop, R., Weinryb, R.M. (2005).  Manualized Supportive-Expressive Psychotherapy Versus Nonmanualized Community-Delivered Psychodynamic Therapy for Patients With Personality Disorders: Bridging Efficacy and Effectiveness. American Journal of Psychiatry, 162, 1933–1940.
Vinnars, B., Barber, J.P., Norén, K., Thormählen, B., Gallop, R., Lindgren, A., Weinryb, R.M. (2007). Who can benefit from time-limited dynamic psychotherapy? A study of psychiatric outpatients with personality disorders. Clinical Psychology and Psychotherapy, 14, 198–210.
Vinnars, B., Thormählen, B., Gallop, R., Norén, K., & Barber, J. P. (2009). Do personality problems improve during psychodynamic supportive-expressive psychotherapy? Secondary outcome results from a randomized controlled trial for psychiatric outpatients with personality disorders. Psychotherapy Theory, Research, Practice, Training, 46(3), 352-375.

Brief Summary

Time-limited manualized dynamic psychotherapy was compared with community-delivered psychodynamic therapy for outpatients with personality disorders.

In a stratified randomized clinical trial, 156 patients with any personality disorder diagnosis were randomly assigned either to 40 sessions of supportive- expressive psychotherapy (N=80) or to community-delivered psychodynamic therapy (N=76). Assessments were made at intake and 1 and 2 years after intake. Patients were recruited consecutively from two community mental health centers (CMHCs), assessed with the Structural Clinical Interview for DSM-IV Axis II Personality Disorders, and included if they had a diagnosis of any DSM-IV personality disorder. The outcome measures included the presence of a personality disorder diagnosis, personality disorder severity index, level of psychiatric symptoms (SCL-90), Global Assessment of Functioning Scale score, and number of therapy sessions. General mixed-model analysis of variance was used to assess group and time effects.

In both treatment conditions, the global level of functioning improved while there were decreases in the prevalence of patients fulfilling criteria for a personality disorder diagnosis, personality disorder severity, and psychiatric symptoms. There was no difference in effect between treatments. During the follow-up period, patients who received supportive-expressive psychotherapy made significantly fewer visits to the CMHCs than the patients who received community-delivered psychodynamic therapy.

Manualized supportive-expressive psychotherapy was as effective as nonmanualized community-delivered psychodynamic therapy conducted by experienced dynamic clinicians.

Evaluation

The main limitation of the study is that the lack of a placebo or inactive control does not allow to conclude that treatment is responsible for the outcomes obtained. However, this is a limitation of all comparative studies that for ethical reasons are forced to eliminate placebo groups. Nevertheless, comparison with naturalistic observations of untreated patients indicates that the present results are likely not due to the mere passage of time.

In conclusion, time-limited manualized supportive-expressive psychotherapy can be introduced in a community setting with promising results. However, it is not superior to psychiatric open-ended nonmanualized dynamic therapy conducted by experienced clinicians.

Contact

Bo Vinnars, Ph.D., M.D.

Karolinska Institutet, SE-171 77 Stockholm, Sweden

Email: Bo.Vinnars@ki.se

Website: http://ki.se/en/people/bovin

The Danish National Schizophrenia project (DNS II): Prospective, comparative, longitudinal, multicentre study of psychodynamic psychotherapy of first-episode psychosis. A controlled design of non-selected, consecutively referred/admitted patients

Harder S, Koester A, Valbak K, Rosenbaum B. Five-year follow-up of supportive psychodynamic psychotherapy in first-episode psychosis: long-term outcome in social functioning. Psychiatry: Interpersonal and Biological Processes, 2014; 77(2): 155-68.

Rosenbaum, B., Harder, S., Knudsen, P., Koester, A., Lindhardt, A., Valbak, K., & Winther, G. Supportive psychodynamic psychotherapy versus treatment as usual for first episode psychosis: two-year outcome. Psychiatry: Interpersonal and Biological Processes, 2012; 75(4): 331-341.

Background

During recent decades, psychodynamic treatment has lacked empirical, systematic outcome studies that it as an evidence-based intervention for patients with schizophrenia spectrum disorders. After 1984 radical conclusions were drawn concerning psychodynamic psychotherapy for patients with schizophrenia:“the evidence from at least half a dozen studies would indicate that no further research on the intensive individual psychotherapy of schizophrenics based on psychodynamic or interpersonal principles is warranted” (Klerman, 1984).

“Individual and group psychotherapies adhering to a psychodynamic model (defined as therapies that utilize interpretation of unconscious material, focus on transference, and regression) should not be used in the treatment of persons with schizophrenia” (Lehman & Steinwachs, 1998, PORT Recommendation, § 22). This recommendation was removed in an update of the treatment recommendation  -   not because it was considered false, but because it was implicitly understood that everyone knew that psychodynamic treatment had been proven ineffective.

Design and Sample

The study was designed as a prospective, longitudinal, comparative, multi-centre investigation. The included patients were offered either: 1) manualised Supportive Psychodynamic Psychotherapy as a supplement to treatment as usual (named the SPP), or 2) TaU for two years (called the TaU).

All centres involved in the study had all shown a previous interest in investigating the methods of supportive psychodynamic psychotherapy, even though not all of them had sufficient resources to offer individual psychotherapy in a systematic way which would be needed for carrying out a randomised controlled study. Thus, a controlled design was chosen in which the centres in both groups included rural and urban sites, university and non-university clinics, as well as large and small departments.

A total of 269 consecutively referred patients with first-episode psychosis of the F2- type according to the ICD-10 were included over two years (October 1997 to September 1999). Fourteen psychiatric centres participated. The SPP group consisted of 119 patients consecutively admitted to eight centres, and the TaU group consisted of 150 patients consecutively admitted to nine centres.

The sample consisted of 181 males and 88 females, mainly of Nordic origin (90%). The patients’ median age at inclusion was 23.7 yrs. (range 16.2-35.9 years), and median age at onset of illness was 20.0 yrs. (range 6-35 years). A total of 48% were living alone, 26% had no friends, 70 % were without education, 22% had not worked within the past year, and 30 % had some kind of moderate substance abuse. The median values for Global Assessment of Functioning (GAF) were 31 for GAFsymptom and 35 for GAFfunction.

Procedures and measures

Patients with a first-episode psychosis admitted to either the inpatient unit or to the community mental health centre, in 1997-1999, were systematically assessed within two weeks to determine whether they conformed to the diagnosis of ICD-10 F20-F29.

The following assessment and measurement scales were used: demographic and socio-economic charts, Operational Criteria Checklist for Psychotic Illness (OPCRIT) (McGuffin, Farmer & Harvey, 1991), GAF in the DSM-IV (APA, 1994), Strauss-Carpenter (Strauss & Carpenter, 1974; Strauss & Carpenter, 1977) and the PANSS (Kay, Fiszbein & Opler, 1987).

The test battery was repeated after two and five years. All assessments were conducted by trained interviewers who were independent of, but not blinded to, the treatments offered to the patients. Reliability testing was made by means of videos of interviews with patients from the different centres.

Allocation to treatment is visualised in Figure 1. In three centres (27% of the sample), patients from the first part of the intake were allocated to the SPP group and from the second part of the intake to the TaU group. No further selection was made regarding this allocation of patients. In five centres (28% of the sample), all patients were offered SPP (in addition to TaU), whereas six centres (45% of the sample) offered only TaU to the project patients.

Interventions

TaU

In Denmark, all TaU-treatment was consistently conducted by a doctor and contact persons from the staff. TaU consisted of different treatment modalities administered according to the patients’ individual needs and available resources at the psychiatric unit at the moment of treatment. Treatment encompassed short psychoeducation programmes, individual meetings with contact persons (mainly nurses and assistant nurses) and other consultants (psychologist, social worker), group meetings, and medical advice (including low-dosis medication).

Psychodynamic supportive psychotherapy

The SPP was based on a model of psychosis that understands the condition as a result of pathogenetic pathways that involve an array of biological, psychological and social risk factors that lead to a disturbed development and functioning in several basic psychological capacities.

The supportive elements in this approach contained, among others, the following:

Helping the patient to understand his/her feelings, attitudes and subjective intentions in the concrete interpersonal relationships.

Helping the patient recover from the psychosocial losses related to his or her suffering from psychosis by, in a trusting manner, reformulate the patient’s story of development with elements of hope and realistic optimism counterbalancing the patient’s negative and self-denigrating attitude.

Applying an array of supportive techniques, including: clarifications, affirmations and suggestions; holding and containing the patient’s painful state of mind; maximising adaptive strategies, encouraging patient activities; helping the the patient to understand how psychotic mechanisms work psychologically in the individual and in the specific interactions with others, and how other people might be expected to react with common sense reactions.

The term ‘psychodynamic’ refers to the following characteristics of the therapeutic approach:

It aims to establish a working alliance that functions even in the periods marked by the patient’s ambivalent, confusing or negative attitude (transference) towards the therapist.

It uses the dynamics of the therapeutic relationship and setting (‘transference’ in a broad sense) to understand communication processes in other relationships outside the setting of psychotherapy.

It emphasises the role and influence of the counter-transference on the therapist’s understanding and responses.

It understands emotions and thoughts communicated in the therapy as instances that illustrate for both patient and therapist what may happen in daily life situations in which the patient communicates and interact with others.

It emphasises the importance and presence of unconscious processes.

It empathises with the patient’s affective states and unresolved states of mind based on a theoretical model for understanding the patient's difficulties in dealing with emotional experience.

It recognises and respects the co-existence of both psychotic and non-psychotic aspects of the personality (Bion).

It acknowledges the importance of developing levels of mental functioning enabling the patient to deal with emotional experiences in a more adaptive way, i.e. ‘turning the raw sense impressions into thoughts’ and ‘thoughts into thinking’ (Bion).

The therapists were psychiatrists and psychologists with an average length of training in psychodynamic psychotherapy, most of them between 1-4 years of training. There was no systematic external control of the therapists’ adherence to the psychotherapy manual, but each case was regularly supervised at the centers which offered SPP as part of the study. Seminars in which the contents and ideas of the manual were presented and discussed in depth were conducted for therapists and supervisors in order to enhance uniformity in therapeutic thinking and conduct.

Results

There was no significant difference between groups at inclusion concerning sex, symptom level as measured by GAFsymptom and PANSS, functional level as measured by GAFfunction, work status and substance abuse.

Reliability

ICC was calculated for PANSS-positive = 0.70, PANSS-negative = 0.74, GAFsymptom = 0.56 and GAFfunction = 0.74. The ICC agreement is thus good for PANSS and GAFfunction, and moderate, but acceptable for GAFsymptom.

At year two, data were obtained from 99 patients (83%) in the SPP group and from 113 patients (75%) in the TaU group. The two attrition groups did not differ at baseline.

Improvement of symptomatology and social function after two years:

The improvement over the two years for the SPP group alone was at a significant level for PANSSpos  (p=0.000; Eta2: 0.50), PANSSneg (p=0.001; Eta2: 0.10), GAFfunction (p=0.000; Eta2: 0.39) and GAFsymptom (p=0.000; Eta2 0.39).

The difference in improvement between the SPP group and the TaU group:

We found significantly higher levels of improvement in the SPP group than in the TaU group for GAFfunction (p=0.000; Eta2: 0.054) and GAFsymptom (p=0.010; Eta2: 0.022), whereas the difference did not reach the level of significance for PANSSpos (p=0.067; Eta2: 0.012) and PANSSneg (p=0.873).

At five years follow-up, 148 (55%) of the patients were re-assessed. No significant differences were found between the degrees of missing in the two intervention groups. Furthermore, patients who dropped out and those who remained did not differ significantly at baseline with regard to social functioning, positive and negative symptoms.

At five year, the analysis of the clinical data using the mixed model for repeated measurement revealed a significant difference between the two treatment groups in favor of SPP for our primary outcome measure of social functioning. For our secondary outcome measures, a significant difference was found for overall symptoms, and for positive psychotic symptoms, whereas no significant difference was found for PANSS negative symptoms. No significant interaction was found between treatment group and time. This indicates a stable superior effect of SPP when compared to ST from 1–5 years.

Strengths and limitations of the study

The strengths of the present study include 1) a large number of consecutively referred patients who were not pre-selected to treatment (neither by themselves, the therapists nor the centres); 2) different types of treatment centres in both the experiemental group and the comparison group (small/big, urban/rural, university/non-university); 3) a large percentages of the Danish population (approx. 25%) is covered by the investigation; 4) SPP therapists with an average level of training were recruited, not just master clinicians; 5) a manual to guide the therapy was deployed; 6) the two groups were compared at the beginning of the investigation on variables of symptomatology (GAF, PANSS), social factors (sex, ethnicity, marital status, habitation, educational level, work, social network and abuse) in order to explore possible bias. No differences between the two groups were found. 

The limitations of the study include a) lack of individual randomisation and b) lack of systematic evaluation of adherence to the SPP psychotherapy manual.

Contact

Prof. Bent Rosenbaum,

Email: bent.rosenbaum@dadlnet.dk

Anna Freud Centre / UCL: Improving mood with psychoanalytic and cognitive therapies (IMPACT Study)

Goodyer, I., Tsancheva, S., Byford, S., Dubicka, B., Hill, J., Kelvin, R., . . . Fonagy, P. (2011). Improving mood with psychoanalytic and cognitive therapies (IMPACT): a pragmatic effectiveness superiority trial to investigate whether specialized psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: study protocol for a randomized controlled trial. Trials, 12, 175.

Midgley, N., Cregeen, S., Hughes, C., Rustin, M. (2012). Psychoanalytic psychotherapy as a treatment for depression in adolescents. Child and Adolescent Psychiatric Clinics of North America, 22, 67-82.

Henton, I. and Midgley, N. (2012) “A path in the woods”: A study of child psychotherapists’ participation in a large randomised controlled trial'. Counselling and Psychotherapy Research, 12, 204-13.

Midgley, N., Ansaldo, F. and Target, M. (2014). The meaningful assessment of therapy outcomes: Incorporating a qualitative study into a randomized controlled trial evaluating the treatment of adolescent depression'. Psychotherapy, 51(1), 128-137.

Brief Summary

IMPACT is a randomised controlled relapse prevention trial aiming to assess and compare the effectiveness of three therapeutic interventions in the treatment and relapse prevention of adolescent depression: Cognitive Behavioural Therapy (CBT), Short Term Psychoanalytic Psychotherapy (STPP) and Specialist Clinical Care (SCC). The trial is a collaboration between the University of Cambridge, UCL and the University of Manchester. The study aims to recruit 540 participants in total aged between 11 and 17 with moderate/severe depression. Recruitment is from Child and Adolescent Health Services (CAMHS) within National Health Service (NHS) Trusts across three major regions in the UK: North London, East Anglia and Manchester and the Wirral.

All participants are randomly allocated to one of the three interventions and after their first therapy session, are reassessed at 6, 12, 36, 52 and 86 weeks. The study is based on an ‘intent to treat’ design and is a pragmatic trial to reflect how these services are provided, and used, in real NHS settings by the adolescent population. An additional aim of the trial is to explore whether, or how, cortisol levels and genes might influence individual responses to treatment; this is being conducted via lab-analysis of saliva samples collected from consenting participants at baseline and at their 36-week follow up assessments. Furthermore, the study intends to estimate the overall health, social and educational costs of the interventions based on research findings, and build ground for future adolescent depression treatment recommendations.

IMPACT also contains two further voluntary sub-branches: MR-IMPACT, which involves using magnetic resonance imaging to explore brain function and intervention effects amongst depressed adolescents, and IMPACT-ME, a qualitative study exploring young people’s experiences of overcoming depression, as well as their expectations and experiences of treatment in the IMPACT trial.

Contact

Professor Peter Fonagy, Professor Mary Target, Dr Nick Midgley – all Anna Freud Centre, and Research Department of Clinical, Educational and Health Psychology, UCL.

email: p.fonagy@ucl.ac.uk

Leipzig Psychoanalytic Child Therapy (PaCT)

Göttken, T., White, L. O., Klein, A. M., & von Klitzing, K. (2014). Short-term psychoanalytic child therapy for anxious children: A pilot study. Psychotherapy, 51(1), 148- 158.
Göttken, T., & von Klitzing, K. (2014). Manual for Short-term Psychoanalytic Child Therapy (PaCT). London: Karnac.
Müller-Göttken, T., White, L. O., von Klitzing, K., & Klein, A. M. (2014). Reflexive Kompetenz der Mütter als Prädiktor des Therapieerfolgs mit Psychoanalytischer Kurzzeittherapie im Alter von 4-10 Jahren  [Maternal Reflective Functioning as a predictor of therapeutic success of psychoanalytic short-term therapy for children aged 4-10 years]. Praxis der Kinderpsychologie und Kinderpsychiatrie, 63, 796-814.

Brief Summary

The Psychoanalytic Child Therapy (PaCT; Göttken & von Klitzing, 2014).) for childen aged 4 to 10 is conceptualised and manualized to treat emotional and affective symptoms. Consisting of 20-25 psychotherapy sessions, PaCT is held in a variety of settings (parent-child, child alone, parents alone), in which a relational theme that has led to the development of a symptom is uncovered and worked through. This relational theme constitutes the focus of treatment, in terms of a psychodynamic hypothesis of the current predominant conflict. Starting from psychoanalytical treatment concepts, PaCT aims for two effects: first, the treatment seeks to alter the child’s mental representations and, by extension, his or her cognitive-emotional style. Second, it attempts to improve the parents’ own insight into the inner psychic states of their child by regular psychoanalytically oriented parental work.

A recent study (Göttken, White, Klein, & von Klitzing, 2014) aimed to investigate the effectiveness of PaCT for 4- to 10-year-olds with anxiety disorders in an outpatient setting. Therefore, a quasi-experimental wait-list controlled study was conducted. Outcomes were assessed with standardized diagnostic interviews and parent as well as teacher reports of internalizing and total problems at three time points. After treatment, over half of the children of the treatment group no longer met the criteria for anxiety disorder while no children of the wait-list group remitted across the wait-list interval. In addition, parent and teacher reports showed significant symptom reduction on internalizing and total problems.

Evaluation

There is a lack of well-evaluated treatment programs for anxiety disorders in early childhood. PaCT may close this gap as it shows that psychodynamic therapy offers an effective line of treatment for childhood internalizing symptoms and disorders in the eyes of clinicians, children, parents, and teachers. It would be worthwhile to extend the evaluation of PaCT by using randomization procedures and larger sample sizes.

Contact

Prof. Dr. Kai von Klitzing

Department of Child and Adolescent Psychiatry, Psychosomatics, University of Leipzig, Germany

Email: Kai.Klitzing@medizin.uni-leipzig.de

Evaluation of two psychoanalytic prevention/intervention programs “Early Steps” and “Faustlos” in day-care centers with children at risk: a cluster randomized controlled trial

Leuzinger-Bohleber, M.; Fischmann, T.; Läzer, K.L.; Pfenning-Meerkötter, N.; Wolff, A.; Green, J. (2011): Frühprävention psychosozialer Störungen bei Kindern mit belasteten Kindheiten {Early prevention of psychosocial disturbances for children with strained childhood}. Psyche – Zeitschrift für Psychoanalyse, 65, 989-1022.
Läzer, K.L.; Leuzinger-Bohleber, M.; Rüger, B.; Fischmann, T. (2013). Evaluation of two prevention programs ‘Early Steps’ and ‘Faustlos’ in daycare centers with children at risk: the study protocol of a cluster randomized controlled trial. Trials 2013, 14:268.
Neubert, V.; Läzer, K.L.; Hartmann, L.; Fischmann, T.; Leuzinger-Bohleber, M. (2014): Early prevention in day-care entres with children at risk – the EVA research project. In: Emde, R.N.; Leuzinger-Bohleber, M. (eds) (2014): Early Parenting and Prevention of Disorder: Psychoanalytic Research at Interdisciplinary Frontiers (pp. 242-259). London: Karnac.

Background

While early programs to prevent aggression and violence are widely used, only a few controlled trials of effectiveness of psychoanalytically based prevention programs for preschoolers have been evaluated. This study compares “Faustlos” (a violence prevention program) and “Early Steps” (a psychoanalytically based, whole day-care center intervention to prevent violence) in day-care centers in socioeconomically deprived neighborhoods.

Methods/Design

Preschoolers in 14 day-care centers in Frankfurt, Germany, participate in a cluster randomized controlled trial (CRCT). The day care-centers were randomly chosen from a representative baseline survey of all Frankfurt’ day-care centers carried out in 2003 (n = 5300) with the following stratifying factors: children’s aggressiveness, hyperactivity, anxiety and socioeconomic status. Additionally, the geographic identification of socioeconomically deprived neighborhoods regarding low income children was taken from the Frankfurt Municipality Statistics. Children’s attachment classification and children’s aggressiveness, hyperactivity, anxiety and social competence are measured as outcome criteria before and after two years of intervention. The programs in the study aim to reach a high-risk population. Therefore, the combination of a random sampling of day-care centers out of a representative baseline survey in all day-care centers in Frankfurt and the application of official data on the local distribution of low income children are unique features offered by the EVA study design. Data on preschooler’s attachment representations are collected in socioeconomically deprived neighborhoods for the first time.

Results

In the EVA study we studied more than 300 „children-at-risk“. Only 35% showed a secure attachment in contrast to 60-70% in normal populations  at the beginning ot the study (see table 1: basic assessment Manchester Child Attachment Story Stem).

The psychoanalytically based prevention programs proved to be highly effective: the psychosocial behaviour of the children impoved by both programs. But only children in the intensive psychoanalytical intervention program EARLY STEPS changed their attachment style from insecure to secure. – The teachers in the EARLY STEPS Kindergartens improved their professional skills, mainly by the regular psychoanalytical case supervision.

Contact

Prof. Dr. Marianne Leuzinger-Bohleber; PD Dr. Tamara Fischmann,

Sigmund-Freud-Institut, Myliusstr. 20, D- 60323 Frankfurt

Email: m.leuzinger-bohleber@sigmund-freud-institut.de

Email: Fischmann@sigmund-freud-institut.de

The influence of a secure attachment relationship under conditions of high risk

Neubert, V., & Läzer, K. L. (2011). Leitfaden für ein Elterninterview zur Erfassung von Risikofaktoren. Unpublished manuscript, Frankfurt am Main.
Neubert, V., Läzer, K. L., Hartmann, L., Fischmann, T., & Leuzinger-Bohleber, M. (2013). Early Prevention in Day-Care Centres with Children at Risk - The EVA Research Project. In R. Emde & M. Leuzinger-Bohleber (Eds.), Early parenting research and prevention of disorder: Psychoanalytic research at interdisciplinary frontiers (pp. 242–260). London: Karnac.
Neubert, V. (2015) Bindung und Risiko – Wie weit reicht die protektive Kraft sicherer Bindung?  Unpublished dissertation, Frankfurt am Main.

Brief Summary

Growing up under conditions that are risky and pose a threat to the children’s development, for instance due to a precarious domestic or socio-economic situation, is no individual case in our society. Especially children who grow up under the above-mentioned circumstances tend to develop psychopathologic abnormalities like internalizing and externalizing behavioral problems. In order to conceptualize specific offers for prevention and support, it is necessary to gain a precise understanding of the risks that the children in question are exposed to. This concerns the direct effects of the risk factors as well as the consequences of their collaboration with protective factors like a secure attachment relationship.

The study at hand analyses the interaction of attachment and risk in terms of the degree of severity of behavioral problems of children in middle childhood who are part of the high risk population of the EVA research study. Data about risk exposure of families and children’s problematic behavior was collected within the scope of guideline-based interviews with parents. Attachment was evaluated with the support of the Manchester Child Attachment Story Task (MCAST).

Main findings of this evaluation refer to the cumulative interaction of risks as well as the influence of single risk factors on the degree of severity of behavioral disorders (e.g. parental stress level, experience of violence within the family, experience of separation within the family). Psycho-social or family-related risk factors appear to be of high relevance whereas class-related or socio-economic factors do not seem to be directly related to the appearance of problematic behavior. Moreover, an interaction of attachment type and the amount of risks in regard to the degree of severity of problematic behavior becomes apparent.

Based on these findings, the thesis argues in favour of the conception of individual prevention and support offers which consider the specific living conditions of children taking part in the research study and, additionally, which start from the relationship level. Standardised programs do not comply with the needs of families with complex structures of environment and relationships in high risk milieus.

Evaluation

We have evaluated the interaction of attachment and risk in terms of the degree of severity of behavioral problems of children in middle childhood who are growing up under high risk conditions. On the basis of this evaluation we argue in favour of the conception of individual (psychoanalytically oriented) prevention and support offers which consider the specific living conditions of children in a high risk milieu and, additionally, which start from the relationship level.

Contact

Verena Neubert

Sigmund-Freud-Institut, Myliusstraße 20, 60323 Frankfurt am Main

Email: neubert@sigmund-freud-institut.de

 The Follow-up in Project EVA: First Results

Läzer, K. L., Leuzinger-Bohleber, M., Rüger, B. & Fischmann, T. (2013). Evaluation of two prevention programs ‚Early Steps‘ and ‚Faustlos‘ in daycare centers with children at risk: the study protocol of a cluster randomized controlled trial. Trials, 268(14).

Neubert, V.; Läzer, K.L.; Hartmann, L.; Fischmann, T.; Leuzinger-Bohleber, M. (2014): Early prevention in day-care entres with children at risk – the EVA research project. In: Emde, R.N.; Leuzinger-Bohleber, M. (eds) (2014): Early Parenting and Prevention of Disorder: Psychoanalytic Research at Interdisciplinary Frontiers (242-259). London: Karnac.

Background

In a sample of so called ›children at risk‹ Project EVA assesses the differential effects of two established prevention programs - Faustlos which is a standardized violence prevention program and the psychoanalytical informed early prevention program Early Steps.

One of the numerous outcome variables of Project EVA is the change of the children’s attachment patterns of the due to intervention. The Manchester Child Attachment Story Task (MCAST) was used prior and after the intervention to monitor the children’s development between the age of 4 and 7. Due to developmental consideration, concerning both verbal and behavioral aspects, the MCAST was no longer appropriate when the children grew older.  Thus the Child Attachment Interview was assessed in a subsample (n = 47) two years later for catamnesis.

Instruments

The Manchester Child Attachment Security Task (MCAST) is a structured doll play methodology which enables identification and detailed classification of internal representations of attachment relationships in young (pre-)school-age children (Green et al. 2000).

The Child Attachment Interview (CAI) is a semi-structured interview which borrows most questions from the Adult Attachment Interview (AAI). The interview tries to assess the children’s capacity to regulate emotions and attention when recounting attachment-related episodes (Target et al. 2003).

Results

The psychoanalytic informed prevention program Early Steps (n = 28) seems to have a positive and substantial effect on attachment security, both in short-term and in long-term development. In contrast, the children in Faustlos (n = 19) did not show significant changes in attachment over the three measurement time points.

Evaluation

Nonetheless those encouraging findings are preliminary and need to be replicated in a larger sample. The research team is currently working on it. The naturalistic design of the study does not allow simplistic interpretations  - but still the results point to the superiority of Early Steps to Faustlos in regard to the effects on attachment security.

Contact

Prof. Dr. Marianne Leuzinger-Bohleber

Email: m.leuzinger-bohleber@sigmund-freud-institut.de

Ulrich Baumann

Email: baumann@sigmund-freud-institut.de

Sigmund-Freud-Institut, Myliusstr.20, D-60323 Frankfurt am Main

The connection between styles of attachment and social behaviour in children of a high risk sample – Empirical study utilizing the Child Attachment Interviews and the Strengths and Difficulties Questionnaire

Leuzinger-Bohleber, M. (2009). Früher Kindheit als Schicksal? Trauma, Embodiment, soziale Desintegration; psychoanalytische Perspektiven (1. Auflage). Stuttgart: Kohlhammer.

Leuzinger-Bohleber, M., Fischmann, T., Laezer, K. L., Pfenning-Meerkötter, N. Wolff, A. & Green, J. (2011). Frühprävention psychosozialer Störungen bei Kindern mit belasteter Kindheit. Psyche – Zeitschrift für Psychoanalyse, 65(09/10). 1-33.

Summary

Many studies conducted in the context of attachment theory already show a connection between attachment and social behaviour. Securely attached children accordingly possess greater social skills. An insecure attachment conversely constitutes a risk factor for the development of adjustment difficulties, problem behaviour and – under influence of other risk factors – also for psychopathological development. These connections were examined in a high risk sample of 44 children between seven and nine years of age as part of this Master's Thesis. The Thesis was carried out in conjunction with the longitudinal EVA-study, the Evaluation of two early prevention programmes in daycare centers that compares two early prevention programmes in daycare centers in Frankfurt districts with increased level of social problems, working with a cluster-randomised controlled trial. The presented study is the first catamnestic examination of the EVA-Study. The hypothesis, that securely attached children are deemed to be more socially competent by their parents than insecurely attached children, was examined, utilizing the Child Attachment Interviews (CAI, Target, Fonagy & Shmueli-Goetz, 2003) and the Strengths and Difficulties Questionnaires (SDQ, Goodman, 1997). This hypothesis could not be upheld. However, the insecurely attached children consistently showed results that were more problematic than those of the securely attached children. The insecurely attached children were significantly younger than the securely attached children. The results were put into context with previous findings, discussed under consideration of methodcritical aspects, and additional research queries were developed.

Aims

- To examine whether there is a relation between the attachment styles and the social behavior of children at the age of 7 to 9 in a high-risk sampl

- To examine the relations between attachment styles and social behavior with the age and sex of the childre

- To examine the influence of the two prevention programs on the attachment styles and on the social behavior

- To generate further research through explorative data analysi

Methods

Participant:

The examined sample is a subsample of the EVA-study (N = 307), which embraces 14 daycare centres in socially deprived neighborhoods, randomly chosen based on a representative survey of all Frankfurt daycare centres in 2003 and social indicators 2008. The participants are randomly assigned to the two intervention programs. The presented study contains N = 44 (22 female) children at the age of 84 and 111 months (M = 97.59 months; SD = 8.19 months). These children belong to 6 of the 14 day-care centres. The parents of all interviewed children were informed about the CAI and agreed to it before we interviewed the children. The interviews were conducted between February 2013 and October 2013.

Data analysis:

A chi-square test was used to examine the relation between attachment and social ehavior. ANOVA and t-tests were applied to differentiate test differences in the social behavior as a function of the attachment style. Furthermore, ANOVA and t-tests were used to examine the relation between attachment style and age as well as social behavior and age. oreover, ANOVA and t-tests were applied to investigate the relation between sex and intervention rogram with attachment style and social behavior.

Results

Attachment and Social Behavior:

Not securely attached children got higher scores on all Problem scales and lower scores on the Prosocial Behavior scale (Not significant: all F < 3.16, al p > .083).

Attachment and Age:

Not securely attached children (A, C, D) are statistically significant younger than securely attached children (t(42) = 2.25, p = .030, d = 0.68).

Social behavior and Age were not related in this sample.

Attachment and Sex:

N = 44, f = 22, m = 2

Girls: B = 54,5%, A = 31,8%, C = 4,5%, D = 9,1%

Boys: B = 36, 4%, A = 36,4%, C = 13,6% , D = 13,6%

Not significant

Social behavior and Sex:

Boys got higher scores on all Problem scales and lower scores on the Prosocial Behavior scale than girls. The results have been significant only for the scale Hyperactivity (F(1,42) = 6.75, p < .013, ηp = 0.14).

Discussion

The hypothesis could not be confirmed. Insecurely attached children in this sample, however, did show more problematic results concerning their social competences compared to securely attached children. Furthermore, the insecurely attached children were significantly younger than the securely attached children. These findings need to be verified in a larger sample. The problem of the possible lacking comparability of different attachment-instruments needs to be discussed and examined in a greater context.

Contact

Marie Luise Teising

Sigmund-Freud-Institut, Myliusstraße 20, 60323 Frankfurt am Main
Telefon: 069 9712040

E-Mail: teising@sigmund-freud-institut.de

 FIRST STEPS:  A psychoanalytically based early prevention for im­migrant families: a cluster randomized trial

Lebiger-Vogel, J.; Busse, A.; Fritzemeyer, K.; Burkhardt-Mussmann, C.; Paul, L.-S.; Leuzinger- Bohleber, M. (2014): First Steps: an integration project for infants with an immigrant background – conceptualisation and first impressions. In: Emde, R.N.; Leuzinger-Bohleber, M. (Eds.): Early Parenting and Prevention of Disorder: Psychoanalytic Research at Interdisciplinary Frontiers (pp. 260-282). London: Karnac.
Leuzinger-Bohleber, M. (2014b): “Out-reaching psychoanalysis”: a contribution to early prevention for “child-at-risk”? In: Emde, R.N.; Leuzinger-Bohleber, M. (Eds.): Early Parenting and Prevention of Disorder: Psychoanalytic Research at Interdisciplinary Frontiers (pp. 20-49). London: Karnac.
Hasselhorn, M.; Andresen, S.; Becker, B.; Betz, T.; Leuzinger-Bohleber, M.; Schmid, J. (2014): Children at risk of poor educational outcomes: Search of a transdisciplinary theoretical framework. Child Indicators Research, 7, 695-697.

Background

The integration of children with an immigrant background is known to have become one of the most urgent social responsibilities in Germany. Children with an immigrant background are still disadvantaged in the German educational system and are more likely to live in high-risk environments. Quite a number of projects supporting the integration of children with an immigrant background into the German society exist although most of them are not scientifically evaluated. Most of them focus on the acquisition German language and therefore address older children (and adults). However, international experts agree that social integration is not only a matter of languages but includes earlier developmental processes of the children in the first months of life connected to adequate early parenting and a prevention of social withdrawal into parallel societies.

Methods/Design

The psychoanalytically based project FIRST STEPS focuses on earliest integration of children with an immigrant background, supporting the parents parenting capacities in the critical phase of migration and early parenthood. By using a prospective randomized comparison group design the effectiveness of a psychoanalytically oriented early prevention program (intervention A) is compared to the outcomes of to groups offered by paraprofessionals (intervention B). Intervention A is a professional offer supporting the immigrant families based on the developmental knowledge on early parenting combining home and center based interventions.I ntervention B is a center based offer by paraprofessionals with an immigrant background. 160 families are randomly assigned to intervention A or B. They are supported and assessed during the first three years of the children’s lives until entering Kindergartens. Social and family stressors, the quality of the parent-child-interaction, child attachment security, the affective, cognitive and social development of the children as well as the social integration of the families are assessed.

Results

Until now 380 immigrant families have been recruited in Frankfurt a. M. and in Berlin. First results show that professionally supported good early parenting (Intervention A) improves  the social-emotional, cognitive and language development of immigrant children as well as the social integration of their families.  Because of these encouraging results, a roll-out across different cities in Germany is planned. Due to the “difficult-to-reach” immigrant families difficulties in recruitment, uptake and retention of participants it was surprising that FIRST STEPs was accepted by these families.

Contact

Prof. Dr. Marianne Leuzinger-Bohleber; PD Dr. Tamara Fischmann, Dr. J.Lebiger-Vogel

Email: M.Leuzinger-Bohleber@sigmund-freud-institut.de

Email: Fischmann@sigmund-freud-institut.de

Email: lebiger-vogel@sigmund-freud-institut.de

 Risk indicators in early emotional development: detection, intervention and follow-up in the first level of care with an interdisciplinary approach

Bonifacino, N.; Mussetti, D.; & Plevak, A. (2011) The pediatric consultation: a first step into infant mental health. Switzerland. Devenir, 23(2):117-27.

Plevak, A.; Schelotto, M.; Bonifacino, N.; & Mussetti, D. (2012) Consulta pediátrica en la primera infancia: una oportunidad para la detección de indicadores de riesgo en el desarrollo emocional: experiencia de tamizaje e intervención precoz. Montevideo. Archivos de Pediatría de Uruguay, 83(2):25-30.

Bonifacino, N.; Plevak, A.; Musetti, D.; & Silveira, A. (2014) Retraimiento sostenido. Un indicador de riesgo en el desarrollo temprano. Detección e intervención en el primer nivel con la escala ADBB. Experiencia en dos centros de salud pública del área metropolitana. Montevideo. Archivos de Pediatría de Uruguay, 85(1):31-39.

Brief Summary

In this work complex psychoanalytical conceptions were taken to an operative field to promote the dialog with related disciplines in an integrative conception of the individual health. From this perspective the psychoanalytical intervention is open to the pediatric medicine interest, recognizing the pediatric consultation as a first step into Infant mental health from the first level of care.

The study was carried out offering pediatricians training in a psychoanalytical perspective of early emotional development and recognizing the relevant position for the intervention of these professionals which are in the closest relationship with the infant and his/her parents. This position is reinforced because of the parents’ transferential aspects that are involved in this professional relationship that take care of the infant´s health. We also offered pediatricians training in ADBB scale (Alarm Baby Distress Scale), which proposes a systematized observation of the infant during the well-baby visit, with the purpose to detect early indicators of relational withdrawal. This is a symptom that is found in the clinic of the most important psychopathological situations of first infancy: attachment disturbances, autism, early interactive difficulties – such as the one caused by the effect of mother depression – post-traumatic syndromes, early relationship difficulties. It also appears as a consequence of organic factors such as sensorial handicaps (auditory and visual), chronic or severe pain, and in sickness. The progressive nature of its installation in the relational pattern of the baby makes its early expressions hard to detect and easily overlooked in the clinical observation without the help of a specific instrument to detect it. The instrument we propose for its detection is simple, accessible and user–friendly. It evaluates 8 items related to the relational pattern of the baby. It is validated in different countries and has a good internal coherence. In a second step of the experience we provide pediatricians trained in the scale, resources to implement interventions oriented by ADBB assessment and aimed to improve the condition of the infants in which indicators of withdrawal were detected. Early detection of withdrawal indicators was done with ADBB scale during well-baby visit to 67 babies between 2 and 14 months, who were video-taped in four pediatric visits during 2010 in two Public Health Centers. Two parallel ways were done to compare results. One pediatrician trained in ADBB since the beginning of the study assessed 30 babies and in the cases which she detected withdrawal, she did interventions oriented to promote in the parents new resources in the interaction with the baby. The others 37 babies were assisted in their regular pediatric visits in the traditional way by other nine pediatricians, who were trained in ADBB and in the implementation of interventions after the second video-taped consultation.

Statistical analysis of the data showed that in the group of 37 infants, 40% presented withdrawal in the 1st. assessment, 57% in the 2nd, and in the 3rd one, which was done after the training, the percentage of withdrawal decrease to 13%. In the parallel group of 30 infants the percentages were: 7% in the 1st. assessment, 13% in the 2nd, 10% in the 3rd, and 3% in the 4th one.

Evaluation

An interdisciplinary approach that includes a psychoanalytic perspective of early emotional development and the use of ADBB scale in the well-baby visit, enables pediatricians to a wider and earlier detection of risk indicators in the infant emotional development, and allows them make efficient interventions which improve the condition of the babies, increasing the quality of the care from the first level.

Contact

Nahir Bonifacino

ADBB Uruguay

Email: nahir.bonifacino@gmail.com

Website: www.adbb-uruguay.net/adbb-uruguay