Psychotherapy Research

Often regarded as the "gold standard' in psychotherapy research. Involves random assignment of participants to experimental conditions, control group(s) and the controlling for irrelevant variables. Difficult to do with long-term psychodynamic therapy

RCT research tends to involve short term therapy
- there is no proof that psychopathology is so malleable that it can be changed permanently by brief intervention. Personality factors are not likely to be changed in brief psychotherapy

Basically can't measure the effectiveness of psychodynamic psychotherapy on characterological psychopathology.

RCT's often look at one disorder in isolation when most patients have comorbidity (multiple disorders)

RCT's often limit measurement to one or two symptoms

Jones: Studies should be longitudinal and finding should be replicated over multiple cases.

Svartberg - RCT showing STPP Effectiveness with Cluster C PD's
- 40wks of STPP or CBT
- Axis I common, usually depression or anxiety
- All patients had avoidant, obsessive-compulsive, or dependent pd's
- manual guided
- reduced symptoms and interpersonal problems during treatment and 2ys. after

RCT showing STPP is cost effective with Chornic Anxiety/Depression
- 8 wks of STPP sessions (interpersonal orientation)
- Control received therapy as usual
- subjects compared to controls had less psychological distress and interpersonal problems 6mths later

Findings
- Dodo bird effect: all therapy treatments studied were equally effective. Dynamic therapy is no better or worse than other treatments. Occasionally different types of psychotherapies were better than others in some studies but the mean level of difference between them tended to be small and non-significant.

Any Therapy is more effective than no treatment
-therapy benefits a majority of patients and is generally more effective than no treatment

Therapy in conjunction with meds is best for many patients.
- together they have a larger effect size than either alone.

Limitations:
Possible researcher bias leading to positive results in all studies

Methodological problems
- such as unsuitable outcome measures and small samples

Support of a helping relationship
Opportunity to express thoughts
Improving self understanding

Psychosomatic Disorder
-Therapy and medical care is best treatment

Panic Attacks and Phobias
CBT treatments appear most effective

Schizophrenia
- family therapy and social skills training may be best treatment

Sheffield Psychotherapy Project - RCT of CBT and STPP on pts with MDD
- 8 wk trials, CBT more efficacy
- at 16wks CBT & STPP were equal

Borderline Personality Disorder STPP Studies
- Transference focused therapy (TFT) based on Kernberg's object relations approach was shown to reduce suicidal behavior
- In comparison among TFT, supportive PP and DBT, all three were found to be about equally effective except supportive therapy did not reduce suicidality

Menninger Psychotherapy Research Project
- blatt's usage of data determined analclitic and introjective psychopathology

Blatt conceptualized that personality development as occurring along two primary lines of psychological development;
- interpersonal relatedness and self-identification (identity)
- Anaclitic and introjective

Object Oriented and Libidinal; Attachment is Preoccupied Insecure
- invovles exaggerated preoccupations with establishing and maintaining satisfying intimate relationships - feeling loved and being able to love.
- Desperately concerned with trust, closeness and dependability of loved others
- development of self is disrupted by intense conflicts about feeling deprived of care, affection and love.
- Analytic psychopathology can occur at several developmental levels, from lack of differentiation between self and other through intense dependent attachment to more mature difficulties in relationships

Anaclitic Disorders - non-paranoid schizophrenia, BDP, dependent PD, hysterical PD, and depression
- Anaclitic depression is characterized by feelings of helplessness, weakness, and depletion. There are intense fears of abandonment and desperate struggles to maintain direct physical contact with the need-gratifying object.

Anaclitic Defenses
- use avoidant defenses (ones which do not allow any concious awareness or discharge of drives) withdrawal, denial, repression so as not to threaten their already tenuous interpersonal relationships

Self Oriented and Aggressive; Attachment is Avoidant Insecure

- involves excessive preoccupation with issues of self. Range from basic sense of separation and differentiation, through concerns about autonomy and control of one's mind and body to internalized issues of self worth, identity and integrity. The development of interpersonal relations is interfered with by exaggerated struggles to establish and maintain a viable sense of self. Central are profound feelings of inadequacy, guilt and difficulty managing affect especially anger and aggression directed toward the self and others.

Introjective disorders
- paranoid schizophrenia, oerideational borderline, paranoia, OCPD, narcissism, schizoid and avoidant PD's, and depression ( Introjective depression, in contrast, is characterized by feelings of worthlessness, guilt, and a sense of having failed to live up to expectations and standards. There are intense fears of a loss of approval, recognition, and love from the object. In each of these types of depression, there are impairments in object representation and there are struggles to maintain contact with objects.)

Defenses
- counteractive defenses (covert or transform conflictual impulses into more acceptable forms that permit partial expression) isolation, intellectualization, rationalization, reaction formation, negativism, projection, undoing, and overcompensation. These defenses allow introjective people to express their underlying impulse to achieve separation and control but in a disguised form.

Analclitics improve more with LTPP supportive expressive therapy than with psychoanalysis
- PSA was more effective in promoting more positive OR's
however supportive was more effective in reducing negative OR's

Introjectives did poorly with brief, manualized therapy and improved more with psychoanalysis
- PSA more effective in reducing negative OR's and promoting positive ones
- with supportive, introjectives showed a decline in positive OR's

Fair better in general - have greater gains than anaclitics
Do better in long-term therapy verse short term. Do particularly poorly in short term (CBT, interpersonal and medication trial)

o better in supportive because it helps them contain emotion and face to face provides more interpersonal connection

Introjectives do better in PSA because of lack of face to face and insights suit need for separateness and intellectual thought

Early - analclitics need support until feel secure, then can begin to seek agency and self definition

introjectives over time will become less self-critical and threatened by closeness so that they can benefit from the therapeutic relationship

Ablon and Jones created a list of 100 measures common to all effective analysis regardless of modality that expert analysts can look far and rate in their examination of tapes and transcripts of therapy sessions

Jones Psychotherapy Process Q-Set
- Psychoanalytic experts judge efficacy of one our PSA, LTPP, and STPP sessions
- Judges used Q-items to define prototype of ideal analytic process
- looks at therapist interpretations of defense instead of whether pt uses defense.
- 9 piles on continuum of least characteristic to most of ideal analysis are made

Study found that PSA had the highest correlation with ideal followed by LTPP then STPP

Jones - that repititions in therapy are two way. Pt does something therapist increases effort to explain.
- research found that therapeutic action is located int he experience, recognition and understanding of the interactions between both client and therapist

Q-Set Study demonstrates there can be consensus as to what constitutes an analytic process, which can then be measured empirically

- single case research indicates there is no one proper analytic process

- interaction structures heal both through insight and therapeutic alliance ie insight and relationship have complementary roles

- Interaction structures are relevant to all of the several theories of psychoanalysis

Major arguments
1. Effect sizes for psychodynamic therapy are as large as those for “empirically supported / evidence based” approaches
2. Active ingredients of these supported therapies include core features long associated with dynamic approaches
3. evidence indicates that the benefits of dynamic treatment are lasting and remain after symptom remission.

Main elements of dynamic therapy:
1. Focus on affect and expression of emotion
2. Exploration of attempts to avoid distressing thoughts and emotions
3. Identification of recurring themes
4. Discussion of past experience (developmental approach)
5. Focus on interpersonal relations
6. Focus on therapy relationship
7. Exploration of fantasy life (free association)

Leichsenring & Rabung, Effectiveness of Long-Term Psychodynamic
Psychotherapy, (2008)
1. Compared long term treatment with shorter cognitive type treatments
2. Effects increased from treatment completion to follow up for all five measures
a. overall effectiveness
b. target problems
c. psychiatric symptoms
d. personality functioning
e. social functioning

Found that the intensity (# of sessions of treatment (not length) correlated significantly with improvement in target problems and general well being in complex mental disorders


o This study showed that LT therapy is significantly superior to ST therapy (in terms of outcome, target problems, personality functioning for the particular pt population being studied).
o Yielded large and stable effect sizes in treatment of pts with personality disorders, multiple mental disorders, chronic mental disorders.
o Effect sizes increased after end of treatment.
o What was important was the number of sessions versus the duration of the treatment.

• This study compared the effectiveness of two short-term therapies and long-term psychodynamic therapy among patients with depressive and anxiety disorders.
• During first year of follow-up, patients treated with short-term psychodynamic therapy recovered faster from both depressive and anxiety symptoms than pts treated with long-term therapy.
• After 3 years, however, there was a stronger treatment effect in the long-term treatment group for pts with both depressive and anxiety symptoms.
• In the long run, long-term therapy was more effective than the brief therapies.