Open door review

Naturalistic, pre-post & quasi-experimental studies

opendoorreview_banner-verlauf.jpg

Overview


peach-5.png

Adelphi University: Psychodynamic Psychotherapy Process and Outcome Research Team

Hilsenroth, M. (2007). A programmatic study of short-term psychodynamic psychotherapy: Assessment, process, outcome and training. Psychotherapy Research, 17, 31-45.
Hilsenroth, M.J., Cromer, T., & Ackerman, S. (2012). How to make practical use of therapeutic alliance research in your clinical work. In Levy, R. A., Ablon, J. S., & Kächele, H (Eds.). Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence. (pp. 361-380). New York: Humana Press.
Kuutmann, K., & Hilsenroth, M. (2012), Exploring in-session focus on the patient-therapist relationship: Patient characteristics, process and outcome. Clinical Psychology & Psychotherapy, 19, 187-202.

Goals

The goals of this ongoing treatment program incorporate an evaluation of interrelated issues regarding psychological assessment, psychotherapy process, treatment outcome and clinical training (see Hilsenroth, 2007 for full description).

Design

The design of this treatment program is primarily an effectiveness model that has integrated the assessment and technique/training aspects of an efficacy model within a naturalistic setting. The participants utilized in this program are patients admitted for individual psychotherapy at a university-based, community outpatient psychological clinic. Patients are accepted into treatment regardless of disorder or comorbidity and assigned to treatment clinicians in an ecologically valid manner.

Method

Patient characteristics, psychotherapy process, technique and treatment outcomes are all evaluated from three perspectives including: patient self-report, therapist ratings, and independent raters using videotape. These measures are administered longitudinally: prior to beginning treatment, at different (standardized) points during the treatment, and at the termination of treatment. Treatment consists of once or twice weekly, videotaped sessions of Psychodynamic Psychotherapy.

Therapists

In this program treatment manuals are utilized for intensive training in technique. However, these manuals are used to aid, inform, and guide the treatment rather than to prescribe it. Thus, therapists are encouraged to provide the interventions in an optimally responsive manner. Advanced graduate students enrolled in an American Psychological Association approved Clinical Psychology Ph.D. program provide therapy in this project. Each therapist receives weekly superivison in both individual and group format that focuses heavily on the review of videotaped case material and technical interventions.

Evaluation

This research program integrates the rigor of assessment and technique training components of an efficacy model within an effectiveness design to exam clinical processes and outcomes of Psychodynamic psychotherapy from multiple perspectives. Incorporation of these efficacy features in a naturalistic treatment setting allows for the examination of therapy process that is more generalizable to applied clinical practice.

Additionally, this program is distinctive in that it was one of the first to examine the effects of a psychological assessment process itself on the ensuing treatment. Limitations include the absence of a control group and the use of graduate clinicians as therapists.

Contact

Dr. Mark J. Hilsenroth

Derner Institute, Adelphi University, Garden City, NY 11530-0701

Email: hilsenrothadelphi.edu

Website: www.adelphi.edu/faculty/profiles/profile.php?PID=0097

Changes in symptoms and interpersonal problems during the first 2 years of long-term psychoanalytic psychotherapy and psychoanalysis

Berghout, C. C., Zevalkink, J., Katzko, M. W., & de Jong, J. (2012). Changes in symptoms and interpersonal problems during the first 2 years of long-term psychoanalytic psychotherapy and psychoanalysis. Psychology and Psychotherapy, 85(2), 203-219.

Objectives

Longitudinal measurements can provide important information regarding variations in developmental trajectories of patients in long-term treatment. The present study investigated changes in general symptoms, depression, anxiety, and interpersonal problems during the first 2 years of long-term psychoanalytic psychotherapy (PP) and psychoanalysis (PA). It was expected that interpersonal problems would diminish more slowly compared to symptomatic dysfunction.

Design

An accelerated longitudinal design with five consecutive measurement points across two cohorts of patients was used.

Methods

Changes on the Symptom Checklist-90-R (SCL-90-R), Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory (STAI), and Inventory of Interpersonal Problems-64 (IIP-64) were investigated during the first 2 years of long-term PP (n = 73) and PA (n = 40). Linear regression analysis was performed to model the different courses of improvement.

Results

After 2 years of treatment, patients in both groups still presented moderate to high levels of symptoms and interpersonal problems compared to non-clinical populations. As expected, interpersonal problems changed less rapidly. PP patients changed both with regard to symptomatic and interpersonal problems, whereas the only significant change in the PA group was on one of the symptomatic subscales. Slopes in the PA group and in PP group did not differ significantly from each other, except for the IIP-64 scale intrusive, with PP patients showing significantly more improvement than PA patients. The height of intake values of the outcome variables appeared to predict the speed of symptomatic recovery.

Conclusions

Symptoms and interpersonal problems did not decrease notably within the first 2 years of psychoanalytic treatment. This is consistent with the idea that significant change takes time for patients with chronic mental disorders and personality pathology. In regular practice, it is advisable to monitor changes routinely in order to identify slow responders more quickly and change the treatment plan, if necessary.

Contact

Netherlands Psychoanalytic Institute, Amsterdam, The Netherlands.

E-mail: Berghout@npsai.nl

The Munich Attachment- and Effectiveness Project (MBWP)

Erhardt, I., Mertens, W., Benecke, C., Zehetleitner, M., & Hörz, S. (2010). Klinische Praxis und formalisierte Diagnostik: Lässt sich der Bericht für den Gutachter mit einem OPD-Rating vergleichen? {Clinical practice and formalized diagnostics: Can one compare both?} Psychotherapie & Sozialwissenschaft, 12(1), 79-106.

Hörz, S., Träger, M., Siegl, G., & Mertens, W. (2011). Einsatz der OPD in der Psychotherapieforschung {Implementation of OPD in psychotherapy research}. Psychotherapie in Psychiatrie, Psychotherapeutischer Medizin und Klinischer Psychologie, 16, 41-54.

Hörz-Sagstetter, S., Mertens, W., Isphording, S., Buchheim, A., & Taubner, S. (2015). Changes of Reflective Functioning during psychoanalytic psychotherapies. Journal of the American Psychoanalytic Association, 63(3), 481-509.

Mertens, W. (2009). Ein jedes Leben ist anders - Plädoyer für eine stärkere Feinauflösung in der Psychotherapieforschung {Each life is different - A plea for more fine-tuned psychotherapy research}. In G. Jüttemann (Ed.), Komparative Kasuistik - Die psychologische Analyse spezifischer Entwicklungsphänomene (pp. 131-139). Lengerich: Pabst.

Goals

The Munich Attachment- and Effectiveness Project (MBWP) is a naturalistic prospective psychotherapy study examining process and outcome of psychoanalytic psychotherapies.

Method

At baseline, the Operationalized Psychodynamic Diagnostics (OPD-2, OPD Taskforce, 2008) were applied. Then, using the Heidelberg Structural Change Scale (HSCS, Rudolf et al. 2000), five therapeutic foci were chosen, reflecting difficulties in relationship patterns (one focus), psychodynamic conflicts (one to three foci) and impairments in personality structure (one to three foci) (e.g. Hörz et al. 2011). For attachment classification the "Adult Attachment Interview" (AAI) and the "Adult Attachment Projective" (AAP) were employed and the "Reflective Functioning Scale" (RF) was applied to the AAI for the assessment of Reflective Functioning. Furthermore, at baseline and at follow-up, a number of self-reports were used: "Gießen-Test", "Narzißmus-Inventar", "Bielefelder Fragebogen zur Klientenerwartung" (BFKE) and "Symptom-Check-List" (SCL-90).

The 20 psychoanalysts recorded several sessions on audiotape at up to five points in time (three to five sessions around baseline, around the 80th session, the 160th session, the 240th session and the 300rd session).

The study was set up following a quasi-experimental design:  half of the psychotherapists (N=10) received an introduction to attachment research applied to the results from their patient's AAI and AAP (two 90 minute sessions per patient, overall 20 sessions). The other ten psychotherapists were introduced to a dream coding method (Moser & Zeppelin, 1996) and spent 20 sessions discussing the application of this method to the initial dreams of their patients and relating these to the psychodynamic impressions emerging from the first therapy sessions. One of our hypotheses examines the question if in the first group this sensitization for questions relating to attachment research could enhance the understanding of separation traumas during treatment and hence lead to a change of the attachment classification.

However, the main focus of this study is on researching microprocesses and interactions (across the mentioned points in time as well as a follow-up assessment one year after treatment). The following instruments were employed: the plan formulation method (PFM) to assess the patient's unconscious therapy goals, his or her pathogenic beliefs, test situations as well as plan compatibility of therapist  interventions; the psychotherapy process Q-Sort (PQS) to obtain the most and least characteristic items regarding patients' behaviors and experiences, therapists' interventions and features of the interaction. In several cases, the Structural Analysis of Social Behavior (SASB), Core Conflictual Relationship Theme (CCRT) or Verbal Elaboration of Affect Scale (GEVA) were employed. We used AAP, AAI, RF, HSCS and self-report measures as outcome measures. The focus of this research project is set on intensive single case studies combining the mentioned process and outcome instruments at various points in time.

A number of research questions emerge from the MBWP. Combining process research, broadened and differentiated using single cases, and outcome findings at different points in time, the following questions regarding process and outcome can be considered relevant:

How good is the concordance between the analysts' descriptions for the peer reports system for psychotherapy and interview ratings based on the Operationalized Psychodynamic Diagnostic System (OPD-2) (Erhardt et al., 2010)? What correspondence between AAI and AAP assessments in this clinical sample can be found (Hörz et al. in prep.)? Which attachment classification can be found in a patient who takes a good course on the HSCS compared to a patient with a poor course on this scale? How does a patient with secure attachment classification (AAI, AAP) change over time in comparison to a patient with insecure attachment classification or unresolved trauma? What influence do analyst's plan compatibility in the sessions have on the treatment outcome? What are the interrelations between PQS findings and therapy outcome? How much do RF and HSCS results correspond? At which point in time do decisive changes in HSCS take place? Can hints for these changes be found in other instruments, e.g. the Narzissmus-Inventar? Can further changes be found between the end of treatment and follow-up assessment?

Another goal of this project is to encourage the discourse about which research methods could be taught in future psychoanalytic training curricula to reduce the gap between scientists and practitioners. Which of the methods are too cumbersome and need too much training, which of the methods can be improved?

Contact

Susanne Hörz-Sagstetter: s.hoerz@psychologische-hochschule.de

Wolfgang Mertens: w.mertens@lrz.uni-muenchen.de

The Frankfurt-Hamburg Long Term Therapy Study

Brockmann, J., Schlüter, T., & Eckert, J. (2006). Langzeitwirkungen psychoanalytischer und verhaltenstherapeutischer Langzeitpsychotherapien. Eine vergleichende Studie aus der Praxis niedergelassener Psychotherapeuten {Long-term effects of long-term psychoanalytic and long-term behavior therapy. - A comparative study from general practices of psychotherapists}. Psychotherapeut, 51, 15–25.
Jakobsen, T., Rudolf, G., Brockmann, J., Eckert, J., Huber, D., Klug, G., . . . Leichsenring, F. (2007). Ergebnisse analytischer Langzeitpsychotherapie bei spezifischen psychischen Störungen: Verbesserungen in der Symptomatik und in interpersonellen Beziehungen {Results of psychoanalytic long-term therapy in specific diagnostic groups: Improvement in symptoms and interpersonal relationships}. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 53, 87-110.
Salzer, S., Leibing, E., Jakobsen, T., Rudolf, G., Brockmann, J., Eckert, J., . . . Leichsenring, F. (2010). Patterns of interpersonal problems and their improvement in depressive and anxious patients treated with psychoanalytic therapy. Bulletin of the Menninger Clinic, 74(4), 283-300.

Brief Summary

The prospective study compares 31 patients in long-term behavior therapy (CBT) with 31 patients in long-term psychoanalytic therapy (PA). A naturalistic design was applied within the German health system. All patients underwent a diagnostic interview (SCID) by an external interviewer. Only patients who fulfilled the DSM III-R criteria for a depression or an anxiety disorder were included in the study. Although the diagnosis of the patients undergoing long-term CBT and long-term PA were comparable, we found that they differed in various ways. (We did not randomise the patients.)

The differences arose in a number of characteristics. PA-patients were higher educated, use less psychotropic medication and had a lower strain of symptoms (SCL-90-R GSI: PA= 0.9 vs. BT=1.5. PA-patients also differed in the access to psychotherapy. They introduced themselves more to therapy (vs. recommended by professionals). The average duration of long-term CBT was 2.4 years and 64 sessions. The average duration of long-term PA was 3.6 years and 209 sessions. Symptoms (SCL-90-R) and interpersonal problems (IIP) were examined at the beginning, after 1 year, 2.5 years and 3.5 years and after 7 years.

Both groups showed significant degrees of improvement within the first 3.5 years and remained stabilized in the following 3.5 years regarding the symptomatic aspects. Focussing on the interpersonal problems, group PA showed further improvement after the 3.5 years period. The CBT group however couldn’t show any further improvement after 3.5 years but they stabilized.

After 3.5 years B -patients had a symptom strain GSI = 0.8 (SCL-90-R) with nearly the same results after 7 years. In other words: CBT patients ended up with a symptom strain with which PA-patients started therapy.

Consume of psychotropic medication was different after 7 years (11% of the PA-patients and 23% of the CBT patients). CBT patients had seen the continuing medication not as a failure of therapy.

Relapses (defined as statistic significant changes at 3.5 years that did not longer exist after 7 years) were low (both 19%) compared to short time therapy relapse rates for patients with depression.

31% of the PA patients and 12 % of the CBT patients have looked for further therapy. The difference between the groups is significant. We did not ask for the reasons why and what kind of therapy they had chosen.

Data of the study were used in other studies (Salzer et al. 2010, Jakobsen et al. 2007)

Conclusions

These results point out why comparison studies concerning the matter of therapy using parallelized samples cannot always match up to reality.

Most patients did profit from therapy and felt satisfied by the therapy, but the profit was different.

Different people choose or are recommended by professionals to different treatments. Treatment theory matters (Fonagy & Allison 2014).

Contact

Dr. Josef Brockmann

Egenolffstr. 29, Frankfurt/M Germany

Email: praxis@dr-brockmann.net

The Heidelberg Berlin Study: Psychodynamic change in two forms of long term psychoanalytic therapy

Grande, T., Dilg, R., Jakobsen, Th., Keller, W., Krawietz, B., Langer, M., Oberbracht, C., Stehle, S., Stennes, M., & Rudolf, G. (2006): Differential effects of two forms of psychoanalytic therapy: Results of the Heidelberg-Berlin Study. Psychotherapy Research 16, 470-485
Grande, T., Dilg, R., Jakobsen, Th., Keller, W., Krawietz, B., Langer, M., Oberbracht, C., Stehle, S., Stennes, M., & Rudolf, G. (2009): Structural change as a predictor of long-term follow-up outcome. Psychotherapy Research, 19, 344-357.
Leising, D., Rudolf, G., Stadler, K., Jakobsen, Th., Oberbracht, C., & Grande, T. (2003): Do interpersonal behavior and emotional experience change in the course of successful longterm psychoanalytic therapies? Psychotherapy Research 13, 461-474.
Rudolf, G., Grande, T., & Oberbracht, C. (2000). Die Heidelberger Umstrukturierungsskala. Ein Modell der Veränderung in psychoanalytischen Therapien und seine Operationalisierung in einer Schätzskala {The Heidelberg Structural Change Scale. A model of change in psychoanalytic therapies and its operationalisation in a rating scale}. Psychotherapeut, 45, 237-246.

Purpose

In this multicenter study process and outcome of two forms of long-term therapies (psychoanalytic and psychodynamic) have been studied. There were three main points of interest: to describe the clinical outcome of psychoanalytic long term therapies; studying psychodynamic nature of change in longer and shorter therapies; identifying predictors for follow-up developments.

Patients have been assigned and treated by experienced psychoanalytic practitioners and have been interviewed and videotaped by members of the study group. Clinical, social and psychodynamic data (rated in the OPD system) were collected by therapists, the study group and patients self reports every three months, respectively six months during the long term therapy and follow-up one and three years after. Those groups were matched in social demographic data and clinical severity.

Results

No difference in global outcome rates between longer psychoanalytic and shorter psychodynamic therapies was found, but the level of structural psychodynamic change (as measured by the Heidelberg Structural Change Scale Scale (HSC) (see Rudolf, 2000) was higher in longer therapies. Structural change at the end of therapy was the best predictor for longterm follow-up development of the patients. The HSC was found to be especially useful for psychodynamic training and quality assessment.

Evaluation

The main interest was to evaluate longer and shorter psychoanalytic therapies under naturalistic conditions. In the videotaped interviews the change of focal psycho­dynamic aspects (“structural change”) were rated by blind raters. Thus the perspective of patients self reports, therapist ratings and the ratings of the independent study group could be compared. For some questions data of this study have been put together with other German studies run in this time (see Jacobsen et al. 2007).

 In consequence of the fact that initial level of patients structural integration (due to OPD) correlated with therapy outcome in the following years we developed a modified psychodynamic therapy for patients with low structural level (Rudolf 2004, 2006, 2013).

Contact

Prof. G. Rudolf, former director of the Heidelberg psychosomatic university clinic.

E-Mail: gerd.rudolf@med.uni-heidelberg.de

PD. Dr. T. Grande

E-mail: tilman.grande@t-online.de

Stuttgart TRANS-OP study

Puschner, B., Kraft, S., & Bauer, S. (2004). Interpersonal problems and outcome in outpatient psychotherapy: Findings from a long-term longitudinal study in Germany. Journal of Personality Assessment, 83(3), 223-234.

Puschner, B., Kraft, S., Kächele, H., & Kordy, H. (2007). Course of improvement during two years in psychoanalytic and psychodynamic outpatient psychotherapy. Psychology and Psychotherapy, 80, 51-68.

Puschner, B., Wolf, M., & Bauer, S. F. (2008). Helping alliance and outcome in psychotherapy: What predicts what in routine outpatient treatment? Psychotherapy Research, 18(2), 167-178.

Objective

To assess and predict level and course of symptomatic improvement in psychoanalytic (PA) and psychodynamic psychotherapy (PD).

Material and Methods

In a comprehensive longitudinal study, course of improvement of 116 patients in PA and of 357 patients PD was tracked over a period of two years and analyzed via hierarchical linear models.

Results

At baseline, over 90% of the patients reported considerable psychological, physical, or interpersonal distress. In both forms of treatment, course of improvement was best fitted by a linear model as compared to a logarithmic one. Symptom distress decreased notably within two years, with an especially sharp decline already before the beginning of treatment. No significant differences between forms of treatment as to level or pace of symptom improvement could be observed. Prediction of speed of improvement was poor, with initial symptom distress showing the strongest influence, while initial helping alliance had no predictive value. When comparing patients who finished their treatment within the two-year observation period to those with still ongoing treatments, the former showed quicker symptom improvement.

Discussion

Implications for psychotherapy provision are pertinent for issues of allocation of ressources.

Contact

Dr. Hans Kordy

Center for Psychotherapy Research, University of Heidelberg

E-mail: hans.kordy@med.uni-heidelberg.de

Implementing panic-focused psychodynamic psychotherapy into clinical practice.

Beutel, M., Scheurich, V., Knebel, A., Michal, M., Wiltink, J., Graf-Morgenstern, M., . . . Subic-Wrana, C. (2013). Implementing panic-focused psychodynamic psychotherapy into clinical practice. Canadian Journal of Psychiatry, 58(6), 326-334.

Objective

To determine the effectiveness of manualized panic-focused psychodynamic psychotherapy (PFPP) in routine care in Germany.

Method

German psychoanalysts were trained according to the PFPP manual. Fifty-four consecutive outpatients with panic disorder (with or without agoraphobia) were randomly assigned in a 2:1 ratio to PFPP or cognitive-behavioural therapy (CBT) plus exposure therapy. Subjects (female 57.4%; mean age 36.2 years) had high rates of psychiatric (68.5%) and somatic (64.8%) comorbidity, and previous psychiatric treatments (57.4%). Assessments were performed pre- and posttreatment and at 6-month follow-up. The primary outcome measure was the Panic Disorder Severity Scale.

Results

Both treatments were highly effective. In patients randomized to PFPP, remission was achieved in 44.4% at termination and by 50% at follow-up (CBT 61.1% and 55.6%, respectively). No significant differences were found. Emotional awareness, a posited moderator of good outcome in psychotherapies, was significantly higher in the CBT group at baseline. It was found to be a strong moderator of treatment effectiveness in both treatments. After adjusting for initial Levels of Emotional Awareness Scale (LEAS) scores, effect sizes (ESs) for the primary outcome were Cohen d = 1.28, from pre- to posttreatment, and d = 1.03, from pretreatment to follow-up, for PFPP, and d = 1.81 and 1.28 for CBT, respectively.

Conclusions

PFPP was implemented effectively into clinical practice by psychoanalysts in the community in a sample with severe mental illness with large ESs. Assessment of LEAS may facilitate the identification of patients suitable for short-term psychotherapy. (Clinical Trial Registration Number: German Clinical Trials Register, DRKS00000245; Universal Trial Number, U1111-1112-4245).

Contact

Prof. Dr. M. Beutel

Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Mainz, Germany.

Email: manfred.beutel@unimedizin-mainz.de

Milan study on facilitated psychoanalytic treatment for adults in collaboration with mental health services

Link: IPA Research Database: http://www.ipa.org.uk

Objectives

The Research project, granted by IPA, was planned by the Study Group for the Adult Facilitated Clinical Service of the Center of Psychoanalysis of Milan, composed of twenty analysts, where treatments are carried out in collaboration with Mental Health Services to favorable economic conditions, with the aim to investigate the subjective changes in patients and the transference-countertransference dynamics, which is recognized to be essential for successful treatment. A main objective is to see whether the economic variables and provenance from public services have an impact on the therapeutic relationship and to verify the potential of the psychoanalytic approach in treatment of severe psychological distress enhancing collaboration with Mental Health Services, taking into account the current socio-economic difficulties. Research questions are: 1. if and to what extent the variables 'money' and 'coming from public services' may influence the therapeutic relationship; 2. which variables are significant; 3. whether psychoanalytic approach can be a valuable instrument enabling severe patients in specific conditions to acquire more appropriate relational and representational capacity, and to improve emotional balance.  

Sample

We have planned to apply the survey on a sample of 20 subjects minimum, selected through contact with mental health services and treated in facilitated psychoanalytic care, comparing them with a control group of equal number of patients treated under the same therapeutic conditions, except for the economic ones. Frequency and setting are kept the same in both groups; the focus is on the evolution of the patient-analyst relationship. 

Instruments

Three tools were chosen for the survey: 1) a form aimed to collect information at the beginning of therapy on objective and subjective data relating to patient (a special tab to collect initial data and Core-OM); 2) administration of OPD (Operationalized Psychodynamic Diagnosis), SCL-90-R (Symptoms Check List- 90-Revised) and the Feeling Word Checklist – 58, to obtain psychodynamic and relational data from patient and analyst; 3) a form for the collection of dreams at beginning and during therapy, according to pre-established steps, to identify the representational ways of the subject.

Current state of research

The development of the study required a first step of preparation, in which have been analyzed in depth the objectives and research instruments, and addressed difficulties related to the carrying out of research in clinical psychoanalysis, achieving the homogeneity of the group; were established the procedures and instruments for conducting the survey, and for selection of patients. A dedicated team was set up in collaboration with the University of Milan, Bicocca, to deal with the research development and to monitor the implementation of the study, according to ethical and clinical issues. Therapists who endorsed the research have been trained in OPD applications and to other instruments' usage. Collection of cases and their monitoring are currently underway.

Evaluation

Since the research is still in progress, we can not produce at the time reliable evaluations on results; however, the preparation and launching of the project have raised interesting issues on conducting research in psychoanalytic without interfering with the natural course of care and the achievement of its objectives. During the research will try to answer these questions.

Contact

Licia Reatto*, Luisa Laghi*, Anna Daniela Linciano*, Pietro Roberto Goisis** 

*  Italian Psychoanalytic Society & IPA

** Italian Psychoanalytic Society & IPA - Coordinator of the clinical Study Group, Center of Psychoanalysis of Milan

Licia Reatto  E-mail: liciareatto@hotmail.com

The DPV Follow-Up Study

Leuzinger-Bohleber, M.; Rüger, B.; Stuhr, U.; Beutel, M. (2002): "Forschen und Heilen" in der Psychoanalyse. Ergebnisse und Berichte aus Forschung und Praxis. Stuttgart: Kohlhammer.

Leuzinger-Bohleber, M.; Stuhr, U.; Rüger, B.; Beutel, M. (2003): How to study the 'quality of psychoanalytic treatments' and their long-term effects on patient's well-being. A representative, multi-perspective follow-up study. The International Journal of Psychoanalysis 84: 263-290

.Brief Summary

In the so-called “DPV Katamnesestudie” [Outcome study of psychoanalyses and psychoanalytic psychotherapies of the German Psychoanalytic Association], we investigated a representative sample of all the patients who had terminated their psychoanalyses and psychoanalytic long-term psychotherapies with members of the DPV between 1990 and 1993 (n = 402 patients). We applied a large variety of different instruments, questionnaires, psychological tests, analyses of “objective data” from the health insurance companies, and intensive psychoanalytic follow-up interviews. The study led to important results: for example, around 80% of all the treatments showed—on average six years after termination—a good outcome according to the evaluations of the former patients, their analysts, independent analysts, and nonanalysts, as well as “objective information” concerning mental health data (significant reduction of costs by a significant reduction of days off work, days spent in hospitals, etc.; see Leuzinger-Bohleber, Rüger, Stuhr, & Beutel, 2002, 2003).

But the most important, often unexpected insights were gained through the 200 intensive, psychoanalytic follow-up interviews with the former patients and with their former psychoanalysts by independent psychoanalytic interviewers. The interviews were mostly tape-recorded or, if patient or analyst did not consent, carefully documented directly after the interview. This documentation proved to be a unique and rich source for psychoanalytic and non-psychoanalytic insights (particularly concerning the tragic findings of the 4% of the psychoanalyses with negative outcomes). The richness of the interview material confronted us with the methodological challenge of how to summarise and communicate the complexity of the conscious and unconscious discoveries of these interviews in a critical way that would be transparent, reliable, and acceptable by members of the psychoanalytic, as well as the non-psychoanalytic, community. In this context, we developed the so-called psychoanalytic expert validation, which proved to be a very helpful and convincing method to summarise the psychoanalytic findings of the follow-up interviews (see ODR: Psychoanalytical Expert Validation).

To mention just one of the unexpected findings: 62% of all the interviewed patients had been severely traumatized children of World War II. Treating children of the perpetrators and the „normal“ German population had been a taboo in Germany for a long time. The unexpected findings of the DPV Outcome Study evoked a broad discussion of this topic within and outside the psychoanalytical community (see e.g. publications by Hartmut Radebold and his team)

Evaluation:

The DPV Outcome Study was the first study investigating the outcomes of psychoanalyses and psychoanalytical therapies by a whole, large psychoanalytical society. Therefore - at the time oft he conceptualization of the study -, only a retrospective design was accepted by the clinicans. Many of them feared that an empirical-prospective study could have negative influences on the psychoanalytical process. –

Because the study was discussed in each assembly of the membership (in all the annual conferences) it evoked interesting and challenging methodological and epistemological controversies in the DPV. This lead to the positive result that many of the analysts became very much interested in empirical research. This is one reason why many of them were now willing to engage in a prospective, randomized outcome study, the LAC Depression Study (starting in 2005). (see summary in the ODR)

Contact:

Marianne Leuzinger-Bohleber: M.Leuzinger-Bohleber@gmx.de

 

Patterns of inner change and their relation with patient characteristics and outcome in a psychoanalytic hospitalization-based treatment for personality disordered patients

Vermote, R., Lowyck, B., Luyten, P., Verhaest, Y., Vertommen, H., Vandeneede, B., Corveleyn, J., & Peuskens, J. (2011). Patterns of inner change and their relation with patient characteristics and outcome in a psychoanalytic hospitalization-based treatment for personality disordered patients. Clinical Psychology and Psychotherapy, 18 (4), 303-13.
Blatt, S. J. (2004). Experience of Depression: Theoretical, Clinical and Research Perspectives. Washington, DC: American Psychological Association.
Blatt, S. J. (2008). Polarities of Experiences: Relatedness and Self-Definition in Personality Development, Psychopathology and the Therapeutic Process. Washington, DC: American Psychological Association.

Brief Summary

The efficacy and effectiveness of psychodynamic treatments for personality disorders (PDs), and for borderline patients in particular, have been demonstrated in a number of randomized controlled trials as well as in naturalistic pre–post studies. In particular, these treatments have been shown to lead to clinically significant improvements in symptom levels, interpersonal functioning and global adjustment. Yet, the fundamental premise of psychoanalytic theories of PD is that besides improvement in symptoms, long-term psychodynamic treatment also results in changes in personality structure or organization. The concept of personality organization (PO) refers to the underlying organization of structural–dynamic components of personality and has been operationalized from different theoretical perspectives in terms of (a) the developmental level of representations of self and others; (b) the capacity for reality testing and maturity of defenses; (c) the background of safety or ‘felt security`; as well as, more recently, (d) the capacity for mentalization operationalized both in terms of reflective functioning and the Bion-Grid Scale. Although changes in PO are supposed to constitute a core mechanism of change in psychodynamic treatment for PD, today only a handful of studies have empirically investigated this assumption.

Based on this, the first aim of this study was to replicate and extend existing research in this area by simultaneously assessing changes in PO using four different measures reflecting different aspects of PO, namely (a) the developmental level of representations of self and others as measured with the DR-S; (b) mentalization as assessed by the Reflective Functioning Scale (RFS) and the GRID; and finally, (c) levels of felt safety as measured with the Felt Safety Scale (FSS). All scales are scored on the Object Relations Inventory (ORI). The second aim of this study was to investigate whether the 44 patients in a psychoanalytic hospitalization-based treatment for PD show different trajectories of change in PO and whether these different trajectories were associated with different pre-treatment characteristics. In particular, several studies have provided considerable evidence suggesting that anaclitic and introjective personality features (Blatt, 2004) are associated not only with different responses to treatments but also with different changes in terms of PO. In this context, Blatt (2004, 2008) has proposed that anaclitic patients are characterized by a distorted preoccupation with relationship issues, such as trust and intimacy, at the expense of self-development, as for instance expressed in dependent, histrionic and borderline personality features. Introjective patients are primarily preoccupied with intense and distorted attempts at establishing and maintaining a sense of self, including feelings of autonomy, self-control and self-worth, at the expense of developing interpersonal relationships, as in schizoid, schizotypic, paranoid, narcissistic, antisocial, avoidant, self-defeating and obsessive–compulsive PDs and features.

The last aim of this study was to investigate whether different clusters of patients were differentially related to outcome. Indeed, some studies have suggested that patients with PDs not only show different trajectories of change during treatment, but that these different trajectories are also associated with different outcomes. For instance, that introjective patients changed primarily in higher levels of thought disorder, whereas anaclitic patients changed more in the more pathological forms of thought disorder. To the best of our knowledge, this is the first study to directly investigate possible associations between different trajectories of change and outcome in the psychoanalytic treatment of PDs.

In line with findings of earlier studies, the results of this study showed that the psychoanalytic hospitalization-based treatment for PDs is indeed associated with changes in different aspects of PO, including representations of self and others, mentalization and felt safety. In addition, this study extends previous studies in that two different clusters of patients could be identified, which showed a distinct pattern of change in PO during and after treatment. On one hand, one cluster consisted of patients who showed a more fluctuating and thus less stable pattern of changes in PO during treatment and at follow-up. The other cluster consisted of patients showing more consistent improvement in PO both during and after treatment. Importantly, further analyses showed that these two clusters showed substantial differences in terms of pre-treatment personality features as assessed by the SCID-II. More specifically, results showed that the more fluctuating cluster seemed to be mainly characterized by anaclitic features as described by Blatt (2004, 2008), as was shown in higher scores on dependent, borderline, avoidant and depressive characteristics compared with patients from the stable cluster. Patients from the more stable cluster, in turn, tended to have higher scores on SCID-II narcissistic PD features, which is in line with Blatt’s suggestion that higher level personality disordered patients with introjective features are mainly characterized by narcissistic characteristics (Blatt, 2004, 2008).

Evaluation

This study including a longitudinal, multi-wave design as well as multi-trait, multi-method approach lends further support to the assumption that psychoanalytic hospitalization-based treatment of PD is associated with changes in PO. Finally, results of this study also suggest that different types of patients may differentially respond to different treatment factors, adding to the growing evidence for the importance of considering patient–treatment interactions in psycho-therapy research towards PO.

Contact

Prof. Rudi Vermote

University Psychiatric Centre, University of Leuven, Campus Kortenberg

Leuvense-steenweg 517, 3070 Kortenberg, Belgium

E-mail: rudi.vermote@uc-kortenberg.be

Website: www.uc-kortenberg.be

Naturalistic outcomes of evidence-based therapies for borderline personality disorder at a university clinic: A quasi randomized trial

Gregory, R.J., Chlebowski, S., Kang, D., Remen, A.L., Soderberg, M.G., Stepkovich J., & Virk, S. (2008): A controlled trial of psychodynamic psychotherapy for co-occuring borderline personality disorder and alcohol use disorder. Psychotherapy: Theory, Research, Practice, Training, 45, 28-41.
Gregory, R.J., Delucia-Deranja, E. & Mogle, J.A. (2010): Dynamic deconstructive psychotherapy versus optimized community care for borderline personality disorder and alcohol use disorders: 30-month follow-up. Journal of Nervous and Mental Disease, 198, 292-298.

Brief Summary

Both Dialectical Behavior Therapy (DBT) and Dynamic Deconstructive Psychotherapy (DDP) are listed in the National Registry of Evidence-based Programs and Practices based on independent reviews of their performance in randomized controlled trials for borderline personality disorder. However, little is known about their effectiveness in real-world settings. DDP is a newer treatment with demonstrated efficacy, but has been less extensively applied than DBT. In a twelve month-controlled trial, thirty subjects with Borderline Personality Disorder (BPD) and co-occuring active alcohol use disorders were randomized to either DDP or optimized community care. Almost half the subjects also met criteria for antisocial personality disorder (Gregory et al. 2008). Following twelve-months of active treatment with DDP, they were then evaluated after an additional eighteen months of naturalistic care in the community. Al applied in treating this low-functioning and highly comorbid BPD population, DDP demonstrated relatively good retention rates and large between-group treatment effects for core symptoms of BPD, depression, parasuicide behavior, alcohol misuse, recreational drug use, inpatient care, and perceived social support (Gregory, Delucia-Deranja, and Mogle, 2010). Although both, DDP and DBT activate autobiographical memory by reviewing specific emotionally charged incidents and behaviors, the therapist stance differs substancially. Whereas the DDP therapist tries to be nondirective and exploratory, thereby supporting individuation, the DBT therapist tries to be validating, directive, educative and pragmatic.

The present study attempts to fill a gap in the literature by using a quasi-randomized design comparing naturalistic twelve-month outcomes of two manual-based treatments for BPD-DBT and DDP-in the real-world setting of a university clinic. A third group of patients, treated with unstructured eclectic individual psychotherapy, served as a control. This study is the first to compare two manual-based treatments for BPD in a real-world setting.

Evaluation

Clients receiving DDP or comprehensive DBT demonstrated significant improvement in symptoms of BPD over time in the intent-to-treat sample, but those receiving TAU did not. Moreover, both of the manual-based treatments achieved significantly greater improvement in symptoms of depression and disability than was found in those receiving TAU. Symptoms of BPD, as assessed by the BEST, improved to a significantly greater degree for clients treated with DDP as compared to DBT demonstrated significantly greater improvement in depressive symptoms, disability and nonsuicidal self-injury than DBT.

A possible explanation for the differences in outcome between DDP and DBT is that CEBI is a specialized tertiary care program that attracts a particularly refractory and comorbid subgroup of BPD clients who have not been preselected for willingness to participate in a research study. In the treatment of severely impaired BPD clients with active co-occuring alcohol use disorders, DDP has demonstrated strongly positive outcomes and relatively good retention (Gregory et al. 2008).

Both DBT and DDP can be effective for borderline personality disorder in the real-world setting of a tertiary care clinic. However, DDP may lead to greater improvement in symptoms and functioning than DBT in this setting.

Contact

Shilpa Sachdeva

713 Harrison Street, Syracuse, NY 13202

Email: sachdeva.shilpa@yahoo.com

Prediction of medium-term outcome in Cluster B personality disorder following residential and outpatient psychosocial treatment

Chiesa, M., Cirasola, A., & Fionagy, P. (2017). Four years comparative follow‐up evaluation of communitybased, step‐down, and residential specialist psychodynamic programmes for personality disorders. Clinical Psychology and Psychotherapy, 24, :1331–1342.

Summary

There is a paucity of research concerning the identification of individual characteristics predictive of outcome in the treatment of personality disorders as there are only a handful of reports that have attempted to identify patients’ clinical characteristics predictive of treatment outcome. 

In this study, we carried out a predictor analysis of a relative homogeneous group of hospitalized patients (n=73) with a standardized diagnosis of cluster b personality disorder (borderline, histrionic and narcissistic), and we attempted to locate the presence of significant predictive factors that influenced positive and negative medium-term outcome. These patients were admitted to two different psychoanalytically-oriented psychosocial programs for personality disorder: (a) long-term inpatient treatment, and (b) a step-down program. Because of the high co-morbidity of diagnosis in the sample, we also set out to evaluate whether specific combinations of diagnostic categories within Axis-I and Axis-II were significantly associated with outcome 24-month after intake in the dimensions of severity of symptoms presentation (SCL-90-R-GSI), social adjustment (SAS) and global assessment of functioning (GAS). In addition, we explored predictors of outcome specific to each treatment in order to refine clinical recommendations for selection for specific programs.

The stepwise logistic regression analysis with improvement status as the dependent variable revealed that the model including self-mutilation the year prior to intake, avoidant PD, intake GAS scores, age at intake and length of treatment was predictive of improvement at 24 months. Cluster B patients with no previous self-mutilation, who did not have a co-morbid avoidant PD, with higher GAS intake scores, longer treatment exposure and younger age were more likely to improve.  Absence of self-mutilation and co-morbid avoidant PD improved 6 and 4 folds the chances to achieve positive outcome, respectively. Six years below the mean age of 30 years, 31 weeks more treatment from the mean of 53 weeks and 6.5 points above the GAS mean score of 46.5 double the chances of improvement two years after treatment intake. Although deliberate self-injury was found to be a negative predictor, improvement rates in self-mutilating patients were significantly different in the two different treatment programs (60% in the step-down program versus 24% in the long-term residential program). A cluster analysis on Axis-I diagnoses identified a larger group whose primary Axis-I diagnosis was major depression and a smaller more heterogeneous group with anxiety or substance misuse diagnoses. No association with improved status at 24 months was found. 

Of the two homogeneous clusters of co-morbid personality disorder diagnoses the large borderline and self-defeating group had achieved significantly greater level of improvement compared to the smaller borderline, avoidant, paranoid, dependent cluster. The difference in outcome between the two PD diagnostic clusters appears to be accounted for by a differential treatment response in program allocation: whereas almost 90% of B-SF patients allocated to the step-down model improved, only 52% of those allocated to the long-term residential program did so.  There was no similar difference between the improvement rates in the two treatment arms for the B-P-A-D cluster. Thus, it seems that therapeutic advantage came especially from the step-down treatment of the self-defeating borderline group of patients.

Discussion

The findings may carry potential clinical implications concerning patient selection and treatment delivery for inpatient and outpatient psychosocial programs for Cluster B personality disorder.  Limitations include a relatively low sample size for a regression analysis, and a larger sample of Cluster B patients may be needed to ensure greater reliability of results.

Contact

Marco Chiesa MD, FRCPsych,

The Cassel Hospital & University College London, Richmond, TW10 7JF, UK

Tel + 44 (0) 20 8237 2902

E-mail: m.chiesa@ucl.ac.uk

Peter Fonagy PhD, FBA

University College London & The Anna Freud Centre

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

Brief Summary

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.

Evaluation

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.

Contact

R.C. Friedman Richard C. Friedman MD
Clin. Prof. Psychiatry
Weill-Cornell Medical College
NYC, New York

Email: rcf2@columbia.edus

From selection to outcome

Erle, J.B., Goldberg, D.A. (2003). The course of 253 analyses from selection to outcome. Journal of the American Psychoanalytic Association, 51, 257-292.

Brief Summary

This paper presents two studies of the clinical work of experienced psychoanalysts, all of them trained at, and members of, the New York Psychoanalytic Institute. Study I is a retrospective study of all of the analytic work of sixteen analysts from 1973 to 1977 (161 patients), including their evaluations of the treatments. Study II is a prospective study of all the patients started in analysis by a group of twenty analysts between l984 and l989 (ninety-two patients) and followed to termination, again including evaluative reports. The participating analysts were not chosen as a representative group; we invited those we thought shared our interest in such a study. Similarly, the patients were not intended to be representative: they were the patients these analysts saw in analysis during the study periods, except those omitted for reasons of confidentiality. The analysts shared the view that analysis had been a beneficial treatment for many patients; each had had experience with patients where an analytic process did not develop.

In both studies, participating analysts reported their assessment of their patients' analyzability at the initial evaluation. These assessments were reviewed, and sometimes revised, in the subsequent periodic reports and at termination. Where an analytic process did not develop, the rating “unanalyzable” was used; in those cases, treatment was interrupted or continued as psychotherapy. We did not attempt to investigate the question of whether work with another analyst might have had a different outcome, either with patients where an analytic process did develop or where it did not. There were reports of patients with histories of apparently unsuccessful analytic treatment who were thought to be analyzable in this treatment.

The rating used here reports only the analyst's view of the outcome of this treatment; that is, the patient is designated analyzable or unanalyzable by this analyst in this treatment at this time. There are a number of factors that could produce different outcomes, such as the influence of a different theoretical position on technique or the impact of a different analyst. Kantrowitz (l995) has drawn attention to the issue of “match,” which she suggests may be crucial to the success or failure of some analytic treatments.

Contact

Joan B. Erle, is Training and Supervising Analyst, New York Psychoanalytic Institute.

Daniel A. Goldberg is on the faculty of the New York Psychoanalytic Institute.

The authors want to express their gratitude for the generous and thoughtful participation of the twenty-four analysts who made this study possible.

Change variables in the psychoanalytic treatment of children and adolescents: A research report

Project

This empirical study was designed to investigate the effectiveness and the variables of change in psychoanalytic treatment of children and adolescents. The survey was conducted collecting information from therapists with regard to a defined number of cases on the development of treatment, and the changes observed. The basic hypothesis was that the change, to be effective, must address the aspects of functioning, the relational (Fonagy, 2002), and the organization of the inner world, as follows from the thought of Sandler (1994). Consequently, were used for the survey questionnaires aimed to collect information about the phenomenal aspects, the relational, the expressions of the inner world, then crossing them. We expected significant results from research as to the therapeutic process and associated variables.

The research described is the first stage of a larger project aimed to investigate also the point of view of young patients. The project, funded by the RAB of IPA, was launched in 2006, after discussion in London at 2005 RTP of IPA. Partial presentation of the results, concerning a comparison between cases concluded and discontinued (drop-outs), took place in Rome, 2008, at ISAPP Conference "New Frontiers of the clinical Research in Adolescence", organized by M. Ammaniti, under the title Variables of change in the therapeutic process of children and adolescents, published in the Conference Proceedings. Additional articles are under completion.

Sample

The research was carried out by asking each of the therapists to answer extensively about a given number of cases, some ongoing, some who had completed therapy, some who had discontinued. Questionnaires were administrated to 125 experienced child psychoanalysts and psychodynamic psychotherapists belonging to Italian Psychoanalytic Society and to accredited Schools in different parts of the country. 24 valid questionnaires were returned, with an average of 19,2%. Overall responses covered 165 treated cases (average 6.79 cases for each psychoanalyst), 87 males and 78 females, distributed in three age groups (0-6, 7-12, 13-18). Of the 165 cases on which we have been answered, 63 cases were completed, 52 still in progress, 50 discontinued; 33 cases had started treatment in early childhood, 60 latency, 67 adolescence, 5 missing.

Treatment

Treatments where therapists were asked to express were conducted with the psychoanalytic method, based on a proper setting and timing, performed by playing, drawings, dreams, in addition to the verbal expression. The duration of the cases discontinued had to be at least six months. No specific forms of pathology were selected for the survey, all forms of distress were included. During the processing of the data, we grouped the pathological forms into six groups relying on the severity and the quality of functioning of the subject.

Measures

Questionnnaires were aimed at highlighting the methodology, the process and the outcomes. We started from the assumption that the quality of development and consequently therapeutic transformation are involving the following areas: the modes of functioning, the quality of the inner world and the characteristics of the relationship or relationality; accordingly, we have formulated questionnaires and asked therapists to express themselves on these areas at different stages of treatment, through multiple choice questions, Likert scales on 4-point and open-ended questions, the latter related to dreams, fantasies and typical ways of behavior (considered an expression of the inner world, Sandler 1994, and of the internal working models, Jones 1997, 2000). When analyzing the unconscious material, the focus was on the relational factor and its level of development. Several findings have emerged; the results of some Likert scales relating to cases concluded and discontinued, where the conclusion was considered one of the indices of therapeutic success, in addition to the quality of the transformations and the functioning characteristics, were cross-validated through comparison with the content of responses to open-ended questions, coded by three independent judges,  (Cohen's K> .7).

Results

By the comments provided by the clinicians:

- a significant finding concerns the fact that the identified variables have a parallel development, concordant in cases concluded, erratic in drop-outs;

- as to the variables, have an influence on the outcome all the processes of acquisition of self-awareness, development of thought and mentalizing, the acquisition of a sense of trust and safety, knowledge and ability to express their own needs, acceptance of the other, the processing of traumatic factors; all the differences between cases concluded and discontinued are statistically significant at the Chi square test with p <0.003;

- a cross-comparison with the content of responses to open-ended questions about dreams, fantasies and functioning characteristics (aimed at assessing the acquisition of ‚internal‘ relatedness) confirmed the results obtained;

- the quality of the relationship is crucial to the development of the therapeutic process, particularly at risk when prevailing feelings of constriction and challenge in the therapeutic relationship;

- the severity of the disorder does not appear to have significant relevance to the outcome;

- work with families appears as a common and positive resource, even if the methodology is not defined; it can be considered as a common evolution in effective technique and probably constitutes an important tool to stop the process of transgenerational transmission of problems and maladaptive patterns of functioning.

Evaluation

Within the limits resulting from a retrospective study, conducted with non-standardized instruments, which involved a sample of therapists, the study provides a survey on the state of things with regard to the psychoanalytic treatment in children and adolescents; the results appear to provide useful information as for the assessment of factors related to therapeutic change, with intersection of phenomenal findings and data from the internal world. The results provided useful basis for switch to the collection of data from young patients.

The comparison between concluded and discontinued cases provides many elements for the evaluation of the cure and the efficacy variables, by showing that the balance of the various factors correlates with good outcome, while the unbalanced development correlates with more pronounced risk elements; major risk factors also correlate with insufficient processing of traumatic elements, insufficient quality of the therapeutic relationship and of the therapeutic alliance (feeling of constriction and challenge). These data were confirmed by the representational modalities of the inner world. The cross-examination of intra-psychic and phenomenal aspects appear ineresting both to the clinic and diagnostic, by indicating ways for measuring the psychic change. The fairly large number of cases described appears to provide greater reliability to the results, to be confirmed by further research on the side of patients.

Contact

Licia Reatto*, Giuseppe Benincasa*, Stefano Castelli**

* Italian Psychoanalytic Society; IPA

** Associate Professor, Bicocca State University, Milan, Italy

Licia Reatto  liciareatto@hotmail.com

Long-term psychoanalytic treatment of ADHD and ODD children: The Frankfurt ADHD and ODD Effectiveness Study

Leuzinger-Bohleber, M. (2010): Psychoanalytic preventions/interventions and playing “rough-and-tumble” games: Alternatives to medical treatments of children suffering from ADHD. International Journal of Applied Psychoanalytic Studies, 7, 332-338.

Leuzinger-Bohleber, M., Canestri, J., & Target, M. (Eds.). (2010). Early Development and its Disturbances: Clinical, Conceptual and Empirical Research on ADHD and Other Psychopathologies and its Epistemological Reflections. London: Karnac Books.

Läzer, K.L. (2015). Effectiveness of psychoanalytic psychotherapy and behavioral therapy treatment in children with attention deficit hyperactivity disorder and oppositional defiant disorder. Journal of Infant, Child and Adolescent Psychotherapy 14(2): 111-128, DOI: 10.1080/15289168.2015.1014991.

The Frankfurt ADHD and ODD Effectiveness Study was conducted between 2005 and 2013 at the Sigmund-Freud-Institut in cooperation with the Anna-Freud-Institut and the child and adolescent psychiatry unit at the university hospital Frankfurt/Main. The research was supported by the German Association of Psychoanalytic Child- and Adolescent Psycho­therapists (VAKJP e. V.); the LOEWE initiative by the state of Hessen, Germany; Zinnkann Foundation; Research Advisory Board of the International Psychoanalytical Association, and the Sigmund-Freud-Institut.

Background

A broader discourse on attention deficit hyperactivity disorder (ADHD) among psycho­analysts started in 2002 with the publication of a special issue of Psychoanalytic Inquiry, claiming that, until relatively recently, a number of practitioners on both sides of the debate from within and outside the psychoanalysis profession had discouraged the use of psychoanalytic treatment for patients with ADHD. Since then psychoanalysts have begun to share their clinical experience of treating ADHD children in several clinical case studies, thus providing psychoanalytic concepts for the understanding and treatment of the triad of inattention, impulsivity and hyperactivity. However, evidence based controlled studies for long term psychoanalytically informed therapies with ADHD children have hardly been performed until now.

Objective

The study explores the effectiveness of long-term psychoanalytic treatment without medication and compares it with behavioral/ medication treatment of ADHD and/or oppositional deviant disorder (ODD) diagnosed children in publicly funded outpatient clinics. It was assumed that psychoanalytic psychotherapy without medication would be at least as effective in reducing the recurrence of the ADHD symptoms among children as a combination of behavioral treatment and medication.

Method

Seventy-three children with DSM-IV diagnosis of ADHD and/or ODD participated in a controlled trial with a naturalistic observational design. The primary outcome was symptom reduction 38 months after the pre-treatment assessment using the diagnostic system for mental disorders in children and adolescents (DISYPS-KJ). Secondary outcomes were significantly lower scores for Conners Parent Scale (CPRS) and Conners Teacher Rating Scale (CTRS), Child Behavior Checklist (CBCL), and Teacher Report Form (TRF) scores.

Treatment

Psychoanalytic treatment consisted of twice weekly therapy sessions of 50 minutes with the child and bi-weekly sessions of 50 minutes with parents provided by psychoanalysts in private practice. The treatment length varied from child to child. In average, the psycho­analytic treatment lasted 25.9 months (SD = 9.62). The manual by A. Staufenberg was developed during the Frankfurt Prevention Study between and was accepted and implemented by all psychoanalysts participating in the study.

Behavioral/medication treatment. Children attended either a manualized six-week concentration-training program or they attended a manualized two week anti-aggression training program. A parent-training program accompanied both programs. Additionally, children were prescribed methylphenidate, if needed, by a psychiatrist. In total, 63.3% of the children were medicated for a time period of 29.6 months on average (SD = 15.89).

Results

Fifty-four children (74.0%) completed the follow-up 38 months on average after the baseline. Both treatment groups demonstrated significant symptom reduction, with no significant differences in effectiveness between the two groups. Teacher ratings as well as parent ratings showed a significant decline over time on the ADHD index scores, on oppositional behavior and hyperactivity/impulsivity levels and on internalizing and externalizing problem scores. Both groups demonstrated similar main effects of time. There were no significant interactions between group and time. The findings support the hypothesis that psychoanalytic psychotherapy without medication is as effective as behavioral therapy and/or medication treatment.

Evaluation

While it is the first study of its kind, the study has limitations. First, the sample size is relatively small. Second, pertaining to the naturalistic design, one weakness is the resulting heterogeneity, which is evident both within and between the groups. This heterogeneity led to a biased sample in certain areas. The strength of the study is the naturalistic design. Psychotherapies were investigated as they were realized in the offices and institutions of ‘real’ psychotherapists with ‘real’ patients in Frankfurt nowadays associated with a high external validity of the findings. The study has scientifically followed severely disadvantaged children with a diagnosis of ADHD and/or ODD and their families over the course of a long-term psychoanalytical therapy and compared them in a naturalistic setting to a comparative group providing already well-validated behavioral/medication treatment. In this respect, the study is pioneer work.

Clinical Trial Registration

DRKS-ID:  DRKS00003356 http://apps.who.int/trialsearch/trial.aspx?trialid=DRKS00003356

Contact

Prof. Katrin Luise Läzer

Email: laezer@sigmund-freud-institut.de

Prof. Dr, Marianne Leuzinger-Bohleber

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

Studies of child analysis practice in the U.S.

Hoffman, L, Karush, R. K., Garfinkle, M. S., Roose, S. P., & Cherry, S. (2009). A cros-sectional survey of child and adolescent analysts in New York City. Journal of the American Psychoanalytic Association, 57(4), 911-917.

Merchant, A., & Hoffman, L. (2013). Raising the curtain: Conversations with child and adolescent analysts In M. O'Loughlin (Ed.), The Uses of Psychoanalysis in Working with Children's Emotional Lives (pp. 341-352). New York Jason Aronson.

Summary

There have been continued questions about the viability of the field of psychoanalysis, especially Child and Adolescent (C/A) analysis. Given the low number of child and adolescent analytic patients, the question must be asked, "Is C/A analytic education and analytic treatment relevant to adult analytic education and, more importantly, to the general mental health treatment of children?” Although there have been many scientific communications about the relevance of C/A analysis to adult analysis, there remains a lack of appreciation of the potential of C/A analysis even by the adult analytic community and in the general mental health field.

In order to understand the problem more clearly and in quantifiable terms, this work is an expansion of prior work by others such as Abrams (1979) that reported that nationally, there was a mean of 2.2 C/A cases per C/A analysts. The first step in our research was to conduct a survey which was reported in JAPA titled, A Cross-Sectional Survey of Child and Adolescent Analysts in New York City (JAPA, 2009, pp 911-917).  This survey demonstrated that the majority of graduate child and adolescent analysts did not have active C/A analytic practices. As a result we developed a semi-structured interview to see if we could identify those factors that contribute to the development of a variety of career paths for C/A analysts.

The interview was divided into three parts:

Demographic and Questions about Professional Experiences

Factual questions about practice and education, incidents or moments in treatment with child, adolescent, and adult analytic/therapy patients and

Personal and social histories of the analysts themselves.

20 Graduate Analysts from Child and/or Adolescent Training programs from NYC and from other parts of the USA were interviewed (recorded with a high level recording device to allow for acoustic analysis). The audio-taped interviews were transcribed and analyzed using the measures of the Referential Process developed by Bucci and Maskit and colleagues. (See Measures of the Referential Process, ODR second edition for details of procedures) .

Demographics

13 males and 7 females; 6 were child psychiatrists, 10 were psychiatrists, and 4 were in other mental health professions.12 were from NYC and 8 from other parts of the USA. Practice: Total number of analytic patients (3 or more times a week): 3.35 per C/A Analyst (compared to 3.2+/-2.6 in the Cross-sectional survey). Number of C/A analytic patients .5 per C/A Analyst (compared to .9+/-1.2 in the Cross-sectional survey). The group was divided into C/A analysts who currently treated C/A analytic patients (8) and those who did not (12).

Analysis of narratives

Thus far we have found that (1) emotional engagement in talking about playing in childhood and continued through adulthood is related to having a C/A analytic practice; (2) a suggestion (which needs to be further corroborated) that C/A who are more emotionally engaged (as evidenced by their high WRAD language) show greater variability in their intensity/loudness of voice; and (3) that all C/A analysts, regardless of their current status of working vs not working with C&A analytic patients, often described their C/A analytic education to have a remarkable impact on the way they understand adult patients, and/or the way they work with patients. The data needs to be further analyzed including completion of acoustic analysis, systematic utilization of the CCRT, and further systematic evaluation of the individual narratives.

Evaluation

If one considers C/A analytic education and treatment relevant to the mental health treatment of children, future generations of analysts need to be educated so that C/A analytic insights can be applied and continue to evolve in a scientific manner. This study can help us understand (1) who is attracted to the field of C/A analysis; (2) who is most likely to be effective as a C/A analyst; (3); how can these qualities be taught to other C/A analysts and C/A students; and (4) can one generalize the findings of this study to all analysts and all students of psychoanalysis, to enable them to engage more patients in analytic treatment

Contact

Leon Hoffman, MD

Email: hoffman.leon@gmail.com

Autor(s) and Affiliation: Leon Hoffman, Wilma Bucci, Bernard Maskit, Sean Murphy: Pacella Parent Child Center, Research Divison, The New York Psychoanalytic Society and Institute

How effective are long-term psychoanalytic treatments in adolescents? A comparison between the evaluations of the patients, their parents and their therapists

Seiffge-Krenke, I. (2010). „Beyond efficacy“: Welche Faktoren beeinflussen die Effizienz analytischer und tiefenpsychologisch fundierter Therapien bei Jugendlichen? {"Beyond efficacy": Which factors influence the effectiveness of psychoanalytic and psychodynamic therapy of adolescents?}. Forum der Psychoanalyse, 26, 291-312.
Seiffge-Krenke, I., & Nitzko, S. (2011). Wie wirksam sind analytische und tiefenpsychologisch fundierte Langzeitpsychotherapien bei Jugendlichen? Ein Vergleich der Einschätzung von Patienten, ihren Eltern und Therapeuten {How effective are psychoanalytic and psychodynamic long term therapies in adolecents? Comparing the ratings by patients, their parents and therapists}. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie, 39, 253-264.

Brief summary of the studies

In the evaluation of psychotherapy outcome with children and adolescents, studies are lacking which analyze psychotherapy outcome from the perspective of different persons involved in this process. In the above studies, treatment efficacy of  30 and 28  long-term treatments with adolescents (mean age 13 years) is presented from the perspective of the afflicted adolescent, his or her parents and his or her therapists. In general, in a study of 30 long-term patients, psychodynamic therapy (mean 97 hours) was effective in reducing symptomatology, both from the perspective of therapist, adolescents and their parents, but the level of change differed significantly. In a second study, the design was further differentiated into a therapy group (n = 28) and a waiting group (n = 32), which did not differ in relevant features such as SES, marital status of the parents, age, gender, and diagnosis of the child. The sample was drawn from an outpatient unit with prevailing internalizing disorders (50.0 %); externalizing disorders (24%), personality disorders (18%) and somatoform disorders (5%) were less frequent. The treatment was psychodynamic therapy with a mean frequency of 89 hours (70 hours for individual treatment of the adolescent and 19 hours for accompanying work with parents).

Assessment were made 3 times over 1.5 years, at the  beginning of the treatment (mean 7 hours), after 40 hours and at the end of the treatment (mean 68hours).For assessments of parents and child, comparable instruments ( YSR and CBCL) were applied.  In the therapy group, the therapists reported a strong reduction in symptomatology (both on a psychic and a somatic level). Therapists further perceived a significant reduction in communicative disturbances of the patient with parents, siblings and friends over time. At the beginning of the treatment, adolescents reported higher symptom levels than their parents. Further, adolescents and their parents reported a significant reduction in symptomatology  over time.  However, parents perceived less change in symptomatology, compared to their children. The diagnosis (internalizing vs. externalizing disturbances) had no impact on the evaluation of treatment effectiveness of adolescents and parents. The quality of the therapists’ work with parents did not impact psychotherapy outcome. Correlations between parents and adolescent  were low (r = .113; ns for internalizing and r = .239;ns for externalizing symptoms) over time.

Conclusions

Earlier studies also have shown low cross- informant correlations between adolescents and their parents regarding the assessment of symptomatology, due to changes in disclosure behavior. Both studies highligh that parents underestimate the severity of symptomatology in their child and also did not perceive as much change during therapy as therapists and children did. Therefore, particularly during the adolescent years of a patient, psychotherapy should include the different perspectives of all persons involved.

Contact

Prof. Inge Seiffge-Krenke

Psychologisches Institut, Abteilung Entwicklungs- und Pädagogische Psychologie, Johannes Gutenberg-Universität,55009  Mainz, Germany.

E-mail: seiffge-krenke@uni-mainz.de

Treatment and rehabilitation of severely traumatized refugees

Varvin, S., & Rosenbaum, B. (2011). Severely traumatized patients’ attempt at reorganizing their relations to others in psychotherapy. In Freedman, N. Hurvich, M., & & Ward, R. (Eds.), Another Kind of Evidence (pp. 167-182). London: Karnac Books.
Varvin S. (2011) Phenomena or data? Qualitative and quantitative research strategies in psychoanalysis. Scandinavian Psychoanalytic Review, 34, 117-123
Varvin, S. (2013). Psychoanalyse mit Traumatisierten. Weiterleben nach Extremerfahrungen und kompliziertem Verlust {Psychoanalysis with the traumatised patient:  Helping to survive extreme experiences and complicated loss}. Forum der Psychoanalyse, 29, 372-389.

This is prospective treatment study of traumatized refugees. The aim is to follow them through two treatment modalities: ordinary outpatient treatment and treatment in psychoanalytic therapy in order to get knowledge on the following topics: personality and extreme traumatization, influence of early (childhood) traumatization and later traumatization, influence of context (especially acculturations stress in exile) on process and outcome, on what works in psychotherapy with extreme traumatized persons.

It is a naturalistic study with no random assignment. The more severely ill patients get psychoanalytic therapy mostly as outpatient clinics did not offer adequate treatment.

Participants

Fifty-four mental health patients with refugee and trauma background were recruited to the study, 35 men and 19 women (response rate 70 %). The participants came from 15 different countries in Asia, Europe, and Africa. They had a mean stay in Norway of about 11 years, ranging from ½ to 28 years.

Procedure

After being accepted for treatment, patients with refugee and trauma background referred to treatment in mental health specialist services either outpatient clinics (treatment as usual) or psychoanalytic private practice treatment.

Research assessment was performed at treatment start (T1), yearly during treatment, at termination (T2), after three years (T4), after five years (T5). Therapists were interviewed with semi-structured interviews after one year (T3), yearly as long as the treatment lasted, and after termination of treatment (T2).

Analysis

Multi method, based on quantitative and qualitative methods.

Contact

Sverre Varvin

Oslo and Akershus University College of Applied Sciences

E-mail: sverre.varvin@hioa.no

Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway

From self-integration in personal schemas of morally experiences to self-awareness of mental states: A qualitative study among a sample of Portuguese war veterans

Kaplan, S., & Laub, D. (2009). Affect regulator in extreme traumatization - Fragmented narratives of Holocaust survivors hospitalized in psychiatric institutions. The Scandinavian Psychoanalytic Review, 32(2), 93-104.

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706.

Varvin, S. (2003). Mental Survival Strategies after Extreme Traumatisation. Copenhagen: Multivers.

Brief Summary

This study explored the understanding of the causes of their distress, the strategies used to cope with posttraumatic symptoms and the key resources and processes to which a group of veterans attributed their recovery from PTSD. Sample was composed of Portugues war veterans (N=60), all males, without brain injury, neuropsychological disorders, physical disability, and psychiatric illness previous to military duty. All participants received a diagnosis of PTSD related to war when they started treatment. Non-recovered group included 30 participants with current positive diagnosis of PTSD, randomly selected among a group of outpatient receiving both psychiatric and psychological treatment for at least the last ten years. Recovered group included 30 recovered patients since negative diagnoses for current PTSD. These participants were randomly selected among a group of former patients and did not receive any treatment during the past year. Participants had no deterioration of their clinical condition following treatment. Both groups showed no differences for demographic, military background, and treatment variables. Two individual semi-structured interviews were conducted. All interviews were audio-taped and transcribed verbatim. Analysis of the interviews’ transcripts was conducted using the Thematic and Categorical Analysis proposed by Bardin (2009). Codes were identified and labelled by tracking language and themes.

Six themes were identified to which participants attributed their recovery: war zone stressors, stressful life events, mental and coping strategies, self-integration in personal schemas of morally incongruent experiences, self-awareness of mental states, and perceived social support. Recovered participants showed higher occurrence of themes related to integration of the morally incongruent events within existing personal schemas or description of a process of transition in the integration of the morally incongruent events within existing self- and relational-schemas, capability to correlate their and others’ behaviors to emotional states or understanding their own mental states and behaviors through the others’ reactions, and description of a wider repertoire of coping strategies to cope with posttraumatic symptoms and current stress triggers. Non-recovered participantes showed higher occurrence of a severe discrepancy between self- and other schemas and the moral injury event, inability to understand their own behavior and other’s intentions and behaviors, childhood idealization, restriction of coping strategies strategies and inadequate or insufficient social support.

Recovery Model

Our findings suggest the benefits of psychoanalytic treatment with traumatized war veterans. Recovery from PTSD among those veterans was related to moral repair and higher mentalization abilities. Moral repair involved a gradual process of self-integration in personal schemas of morally incongruent experiences (Horowitz, 1992; Litz et al., 2009) resulting in the restoration of a sense of coherence achieved through assimilation of a new image of the body, images of others, and values and ideals in the structure of the self (Herman, 1992). Higher mentalizations abilities enabled recovered patients to find meaning to traumatic events and helped them to create a coherent narrative about the patient’s childhood history. This achievment seems to play a key role in recovery of self-concept and identity coherence (Horowitz, 1992).

These findings should be tested by using a longitudinal design to analyse the evolution of these processes in the psychoanalytic treatment of those patients. This framework should combine research on process and outcome.

Contact

Paulo Correia Ferrajão

Instituto Superior de Psicologia Aplica, Rua Jardim do Tabaco, 34, 1149-041 Lisbon, Portugal

Email: pauloferrajao@gmail.com

Psychotherapy utilization and care for severely disturbed patients

Löffler-Stastka, H., Voracek, M., Leithner, K., Fischer-Kern, M., Presslich, E., Kunz, C., &  Meisel, T. (2003). Predicting psychotherapy utilization for patients with borderline personality disorder. Psychotherapy Research, 13(2), 255-264. doi: 10.1093/ptr/kpg023.
Löffler-Stastka, H., Blueml, V. & Boes, C. (2010). Exploration of personality factors and their predictive impact on therapy utilization: The externalizing mode of functioning. Psychotherapy Research, 20 (3), 295-308. DOI: 10.1080/10503300903436710.
Löffler-Stastka, H., Frantal, S., & Jandl-Jager, E. (2010). Überweisungserfolg in Psychotherapie bei Patienten mit Persönlichkeitsstörungen – Therapeutische Konsequenzen [Referral success to psychotherapy of patients with personality disorders – therapeutic consequences]. Wiener klinische Wochenschrift, 122(5-6), 165-172.

Brief Summary

Psychotherapy plays an important role in the treatment of patients suffering from a personality disorder. It is known that many patients with personality disorders do not take up psychotherapy or drop out of treatment prematurely. The aim of the present study was the detection of factors in patients with personality disorders which influence the referral to psychotherapy.

After an exploratory study with psychiatric inpatients in 2003, personality characteristics (socio-demographic parameters, affect experience and regulation, quality of object relations, character traits, level of interpersonal problems) of 297 patients of a psychoanalytic-psychotherapeutic outpatient clinic were assessed. Their influence on therapy engagement were analysed by means of logistic regressions. Within univariate analysis certain personality traits (mature psychological functioning vs. negativistic personality features) showed predictive power. The multivariate analysis identified the patients’ educational level as the principal indicator for psychotherapy utilization. Consequences for diagnostic initial interviews in connection with the role of the educational level for the therapeutic alliance are discussed. Further, the impact of economic aspects on therapy engagement is discussed.

Contact

Henriette Löffler-Stastka, Assoc.Prof.in Priv.-Doz.in Dr.in

Medizinische Universität Wien, Universitätsklinik für Psychoanalyse und Psychotherapie, Währinger Gürtel 18-20, 1090 Wien

E-mail: henriette.loeffler-stastka@meduniwien.ac.at

Effectiveness of psychoanalytic psychotherapy for children and adolescents with severe anxiety, depressive, and disruptive psychopathology in a naturalistic treatment setting

Weitkamp, K., Daniels, J. K., Hofmann, H., Timmermann, H., Romer, G., & Wiegand-Grefe, S. (2014). Psychoanalytic psychotherapy for children and adolescents with severe depressive psychopathology – preliminary results of an effectiveness trial. Psychotherapy, 51, 138-147.

Methods

This partly waitlist-controlled field study aimed to evaluate the effectiveness of psychoanalytic short and long term psychotherapy for children and adolescents employing a prospective design.

231 children and adolescents (aged 4 to 21 years) and their parents who entered psychoanalytic therapy in private practices in northern Germany participated in this ongoing study (154 intervention group, 23 wait-list control and intervention group, and 54 wait-list control group). Data was collected from therapists, parents, and from the patients (aged 10 years and older) at the beginning and the end of treatment, as well as up to 5 points in time during therapy. Follow-up took place at 6 and 12 months after therapy. Amongst other measures, depressive pathology was measured with the CDI, anxiety pathology with the SCARED, disruptive pathology with the external symptom score of the CBCL/YSR, and quality of life with the KIDSCREEN.

The patients received individual psychoanalytic psychotherapy which was predominantly child-focused, complemented by parent sessions usually on a ratio of 4:1. The interventions were based on Anna Freud (1949/1980) and object-relations theory as set out by Winnicott (1958/1988). The actual applied practice of psychoanalytic psychotherapy in children and adolescents was written down in a field manual (Baumeister-Duru, Hofmann, Timmermann & Wulf, 2013). Adherence to this code of practice was checked with a retrospective treatment fidelity checklist filled out by the therapists at the end of treatment for each patient. 

Data analyses were carried out using intention-to-treat (ITT) analysis. Missing values were analysed and imputed with expectation maximation (EM). In addition to ANOVAs with repeated measures, mixed linear models were utilised to take into account the nested structure of the data, e. g. therapists treating more than one patient.

Results

Overall, patients showed pronounced impairments at the commencement of outpatient therapy.

Depressive group 50 patients were included in the depressive group. Patients received, on average, 97 sessions of therapy (range: 25-205). At the end of therapy, there was a significant reduction in depression in the treatment group (parent report: d=.88; patient report d=.68). The wait-list control group, which received minimal treatment, displayed a slight, but not statistically significant, symptom improvement in the patient report (d=.07), but a significant improvement in the parent report (d=.49). 66% of the patients could be rated as recovered or improved. At the time of the publication follow-up was still being collected and hence, could not be published (Weitkamp, K., Daniels, J. K., Hofmann, H., Timmermann, H., Romer, G. & Wiegand-Grefe, S.,2014). Analyses with the completed data-set indicate stable results comparable to the anxiety and disruptive pathology.

Anxiety group The 76 anxiety patients received on average 94 therapy sessions (range: 8-300). Both, parents and patients in the intervention group reported moderate symptom improvements at the end of therapy (parent: d=.58; patient: d=.57), which are stable at the 1-year follow-up and increase from the patient perspective (parent: d=.37; patient: d=.80). When comparing the first therapy interval with the (minimal treatment) wait-list control group, both groups improved significantly with small effect sizes and no significant group differences. 69% of the patients could be rated as recovered or improved (Weitkamp, K., Daniels, J. K., Baumeister-Duru, A., Wulf, A., Romer, G., & Wiegand-Grefe, S., in prep.).

Disruptive group On average, the 65 intervention patients received 94.8 sessions (range: 19-300). Both, parents and patients in the intervention group reported moderate improvement of disruptive pathology at the end of therapy (parent: d=.69; patient: d=.63), which are stable at the 1-year follow-up (parent: d=.77; patient: d=.68). When comparing the first therapy interval with the (minimal treatment) wait-list control group, both groups improved significantly in the parent view on disruptive pathology with no significant group differences. The patients noted no significant differences neither in the first therapy interval nor the    wait-list group (Weitkamp, K., Daniels, J. K., Daubmann, A., Romer, G., & Wiegand-Grefe, S., in prep.).

Evaluation

The results suggest that psychoanalytic therapy is successful in alleviating different kinds of pathology and improving quality of life for children and adolescents. These effects remain stable across one year follow-up. This naturalistic study is high on external validity with some limitations attached: the control interval had a much shorter duration than most therapies and these wait-list patientes received more often than not some supporting sessions. The therapy duration showed large variance. Lastly, the three symptom groups were not mutually exclusive, in a number of cases patients reported comorbid pathology.

Contact

Prof. Dr. Silke Wiegand-Grefe

Medical School Hamburg

Email: silke.wiegand-grefe@medicalschool-hamburg.de

Prof. Dr. Georg Romer

Email: georg.romer@ukmuenster.de

Rorschach perception and thinking domain and mentalization based treatment: an outcome study

Del-Ben, C., Vilela, J., Crippa, J., Hallak, J., Labate, C., & Zuardi, A. (2001). Confiabilidade teste-reteste da Entrevista Clínica Estruturada para o DSM-IV – versão clínica (SCID-CV) traduzida para o português. Revista Brasileira de Psiquiatria, 23, 156-159.

Abstract

The objective was to identify perception and thinking changes in patients treated by psychoanalytical psychotherapy at a university public outpatient service. 68 patients participated, mainly women (80.9%), around 40 years old, and 11.5 years of education, who attended at least one session weekly for two years with a trainee therapist, psychiatrist or psychologist. The majority met the criteria for Major Depressive Disorder, (DSM-IV, Axis-I), and Cluster B and Cluster C on Personality Disorder (DSM IV, Axis-II). The Rorschach was administered upon admission and in annual follow ups. An adaptation from the Comprehensive System to the R-PAS was performed.  The results showed statistically significant differences were found on the Perception and Thinking variables, indicating structural changes were achieved.

 Social avoidance behavior, alexithymics more often stop their inpatient treatment in the early phase of therapy. At baseline, alexithymic patients show higher levels of psychopathological distress compared to nonalexithymics. The symptom reduction in alexithymics is lower and the psychopathological distress at the end of the intervention is still significantly higher than in nonalexithymics. There are no or only little changes in Toronto Alexithymia Scale scores in both groups over the course of the treatment.

The residency program in psychiatry and the specialization program in health psychology of a school of medicine, EPM, include training in psychodynamic psychotherapy. Besides attending a theoretical course, the trainees must treat at least two patients deemed suitable for long-term psychodynamically oriented psychotherapy, once a week. The trainees meet weekly with a supervisor in a group session to discuss the progress of the therapy until the end of the program, after two years. The supervisors are staff members of the Department of Psychiatry with a solid foundation in psychoanalysis.

The proposal of the study was to assess the effects of the psychotherapeutic treatment on the patients. The school hospital, including its outpatient services, is a free of charge institution.

In order to carry out this proposal the patients, upon admission, were submitted to the Structured Clinical Interview for DSM-IV (Axis-I, and Axis II) by trained psychiatrists, following these criteria (a) inclusion: at least 18 years of age, interest and availability to attend the psychotherapeutic sessions; and (b) exclusion: schizophrenic disorder, antisocial personality disorder, dementia disorder, mental retardation. The Rorschach method was the selected psychological instrument for assessing the possible changes in personality aspects, and was administered upon the admission of the patient, and after one and two years of psychotherapy.

The sample comprised 68 patients, mainly women (55 or 80.9%), with the mean of 39.7 years old, and with the mean of 11.5 years of education, who attended at least one weekly psychotherapy session for two years. As to the diagnosis, 46 (67.6%) patients met the criteria for Major Depressive Disorder (DSM-IV, Axis-I), and 44 (64.7%) met the criteria for Personality Disorder (DSM-IV, Axis-II) with the prevalence of cluster B (borderline, narcissistic histrionic or antisocial) in 27 (39.7%) patients, followed by cluster C (avoidant, dependent or obsessive-compulsive) in 17 (25.0%) of patients.

The Rorschach was administered according to the Comprehensive System (Exner & Erdberg, 2005) and an adaptation to the R-PAS (Meyer, Viglione, Mihura, Erard, Erdberg, 2011). A statistical comparison was performed between time 1, that is, upon admission (t1) and after two years of treatment, that is, time 3 (t3).

The variables of Perception and Thinking Domain are (1) Ego Impairment Index-3 ;(2) Thought and Perception Composition  (3) Weighted Sum of the six Cognitive Codes; (4) Severe Cognitive Codes; (5) Form Quality Percentages  ; (6) Popular [P].

Statistical significant differences were found on four out of the six variables of the Perception and Thinking Domain.

The changes toward improvement on perception and thinking are notable, meaning a cognitive improvement among the patients as to reality testing, more conven