Factors affecting change in private psychotherapy patients of senior psychoanalysts: An effectiveness study
Friedmann, R., Garrison, W., Bucci, W., & Gorman, B. S. (2005). Factors affecting change in private psychotherapy patients of senior psychoanalysts. Journal of the American Academic Psychoanalysis and Dynamic Psychiatry, 33(4), 583-610
There is a need for studies that provide systematic data concerning the complexity of psychodynamic psychotherapy as actually practiced in the community (Nathan, Stuart, & Dolan, 2000; Erle & Goldberg, 2003). The present report begins to address this need. The report covers data for private patients of experienced psychoanalytic practitioners; these patients present with a wide range of psychiatric symptoms and disorders, including multiple disorders. We also compare patients who received psychopharmacological treatment concurrently with psychotherapy with those receiving psychotherapy alone. The fact that all of the therapists who provided data were physicians is relevant here because they could conveniently prescribe medication as clinical judgment dictated without being concerned about splitting the treatment. A structured interview was constructed and administered to 51 psychoanalytic physicians respondents by graduate students and research assistants under supervision. Each of 51 experienced psychiatrist/psychoanalysts was queried about the clinical characteristics of every private psychotherapy patient presently in treatment: 551 patients were included in the study; 88% of patients had an Axis I disorder, 59% had Axis I and Axis II disorders concurrently, and 11% Axis II only. Of these patients, 44% had been prescribed psychotropic medication on a daily basis for at least two weeks during the present treatment. Patients treated for the longest time (five years or more) were the most seriously psychiatrically disturbed. Patients improved with psychotherapy, and the improvement was related to the duration of treatment. The combined impact of diagnosis status, treatment duration, and treatment modalities provided a consistent pattern of treatment effectiveness.
There have been no previous investigations of the clinical characteristics of patients treated by experienced psychiatrist-psychoanalysts with various types of dynamic psychotherapy, in treatments of varying durations. In fact, there has been no previous demonstration that collection of data from such a group is feasible. Much psychotherapy research is split off from psychotherapeutic practice as it is actually carried out in the community. Hence, therapists often view research as useful in the abstract, but not particularly relevant to their vocational lives or their identities as psychotherapists. For example, controlled, manual—based psychotherapy research is admittedly of great importance for treatment development and evaluation, and specialized clinics at major treatment centers offer treatment based on such manuals. Nonetheless, most psychotherapy is not offered in such settings, and the proportion of psychotherapists throughout the world who offer treatment based on manuals is negligible. In our design, we were guided by a need for clinical relevance; our study is aimed at the clinical judgments of practitioners across the full range of their patients. What we have tried to provide here is a cross—sectional snapshot of the private practices of senior, analytically trained psychiatrists, the patients, the treatments, and the treatment effects.
This investigation was labor—intensive. Psychoanalysts who provided data about their patients were willing to spend much time with our graduate student interviewers and participated with enthusiasm. Our study indicates that the general body of knowledge and beliefs termed “psychoanalytic,” particularly as represented in treatments characterized as “uncovering,” appears to be therapeutically helpful to patients engaged in ongoing treatment, including patients who present with severe symptoms. We made no effort to ascertain the beliefs by therapists about the reasons for therapeutic progress, and we did not attempt to study specific therapeutic interventions. Precisely what the underlying assumptions that guided these treatments were remains to be examined in future research. Ideas that were once universally accepted, such as the central role of the Oedipus complex in development and psychopathology, and the role of transference in psychoanalytic treatment, have been the subject of recent criticism. Debates between psychoanalysts of different schools (e.g., drive— conflict theory vs. object relations or self psychology) and different perspectives (e.g., one person vs. two—person psychologies) continue unabated. Our impression was that such debates were peripheral to the therapeutic work carried out by the clinicians who participated in this study.
R.C. Friedman Richard C. Friedman MD
Clin. Prof. Psychiatry
Weill-Cornell Medical College
NYC, New York