Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.     

Post natal depression,the mother's conflict and parent – infant psychotherapy

This paper sets out to consider a psychodynamic approach to postnatal depression. In particular, it examines the advantages of psychodynamic parent?–?infant psychotherapy both as a treatment model, and also as a way of thinking that can help to formulate a theory of the postnatal period. An illustration is provided in the clinical account of the therapy of a couple and their nine-week-old infant. The author draws on this example, and on findings from psychoanalytic theory, infancy research, evolutionary biology and anthropology to suggest an integrated understanding of the postnatal state of mind and its challenges.     

心理治疗中共同要素理论的历史发展

从共同要素的角度,分理论模式化与研究实证化两条线索,追溯了心理治疗中共同要素理论的思想渊源,并自Saul Rosenzweig开始,综述了Carl Rogers、Jerome Frank、Marvin Goldfried、Michael Lambert、Bruce Wampold等学者的观点,探讨了共同要素理论的历史演进、内涵结构、理论模式及当代研究进展。认为它在不久的未来,将与特殊技术说逐步走向整合,加深对心理治疗过程与改变机制的认识,共同提升心理治疗的效果。     

Treating Depression in Older Medical Patients with Psychotherapy

This purpose of this paper is to discuss the effectiveness of psychotherapy for treating depression in older, primary care patients. This paper highlights the feasibility of implementing psychotherapy in primary care settings, patient preference for psychotherapy, and the utility of primary care versions of therapy in treating depression in older adults. The discussion is supported with examples from three ongoing research projects, specifically the San Francisco General Hospital Depression in Late Life Study, the Hartford Foundation/California Healthcare Foundation IMPACT study, and the NIMH PROSPECT study. The findings presented here support the value of offering psychotherapy as a treatment alternative in primary care medicine.     

Psychoanalytic treatments and empirical research on their efficacy: A commentary

Abstract

The author summarizes the problems inherent in nomological approaches examining the efficacy of psychoanalysis as a form of treatment. He argues that nomologically oriented research operates with assumptions lacking empirical foundation and, moreover, that studies of this type merely give the impression of the effectiveness of psychoanalytic therapies while overlooking the specificity of the psychoanalytic method. He suggests that research into psychoanalytic treatments should not be subjected to a nomological conception of science, and that structural analysis of treatment courses should be examined and systematized within the frame of psychoanalytic treatment theory relative to their outcome. Given this approach, and provided that the theory of treatment is based on conceptual common ground, such studies would enable a prognostic conclusion that psychoanalytic treatments are successful, providing that the sequences generalized in the treatment theory do actually take place in treatments that take patients’ individuality into account.     

Breathwork: An Additional Treatment Option for Depression and Anxiety?

Breathwork is an increasingly popular experiential approach to psychotherapy based on the use of a specific breathing technique, however, claims of positive mental health outcomes rely on anecdotal clinical evidence. To ascertain the likely efficacy of breathwork this review clarifies the approach and its theoretical assumptions and examines relevant empirical research relating to breathing inhibition, suppression of inner experience, and possible neurological and physiological effects. Additionally, research into mindfulness-based psychotherapy and yoga breathing-based interventions with comparable features to breathwork are examined. Findings suggest qualified support for the key theoretical assumptions of a three component breathwork model, referred to as Integrative Breathwork Therapy (IBT), and its possible utility in the treatment of anxiety and depression. Further research aimed at exploring specific efficacy of this approach for these disorders may yield a useful additional treatment option utilising a different process of change to existing treatments.     

Doing things differently: an appreciation of Meltzer’s contribution

In this paper I wish to draw attention to aspects of Donald Meltzer’s ways of working which characterised his practice as a psychoanalyst and which I consider important in appreciating his originality. Several central themes are described and elaborated including: the central relevance of child analysis and the unity of child and adult analysis; the value of working in a clinical group with colleagues; the revision of psychoanalytic theory; joint research and writing projects; Meltzer’s recognition of the power of infant observation as a tool for learning; the commitment to a wider psychoanalytic culture; the particular contribution to the Tavistock child psychotherapy training. Examples from Meltzer’s written archive, both his books and papers, are used to demonstrate and illuminate these themes, alongside clinical material from child psychotherapy work brought to the author’s attention in supervision.     

An overview of the treatment of severe narcissistic pathology

This paper provides an overview of narcissistic personality disorders as they present clinically along a spectrum of severity ranging from the best functioning forms of pathological narcissism to the most threatening to the patient's psychosocial and physical survival. It proposes a general interpretive psychoanalytic stance with all these clinical syndromes that range from standard psychoanalysis to a specific psychoanalytical psychotherapy for the most repressive and life threatening conditions that may not respond to standard psychoanalysis proper. This general psychoanalytic approach is placed into the context of related developments in contemporary psychoanalytic understanding of pathological narcissism and its treatment.     

Supportive psychoanalytic psychotherapy for borderline patients: an empirical approach

The author describes a reformulation for research purposes of a supportive psychoanalytic therapy for patients with borderline personality disorder. The major influences on the thinking that led to the modification of prior formulations and the historical background of treatment manuals are described. Supportive treatment is contrasted with transference-focused psychotherapy and dialectic behavior therapy in the interest of creating a clear comparison that lends itself to empirical study.     

Broken Bounds: Contemporary reflections on the antisocial tendency

When embarking on research into the effectiveness of psychoanalytic psychotherapy in the NHS or the application of psychoanalytic principles, researchers come up against a number of hurdles: many clinicians still see empirical research as antithetical or disruptive to the practice of psychoanalytic psychotherapy; psychoanalytic psychotherapy has previously fared poorly in evidence-based policy guidelines and this can discourage ambition, and there are technical problems of research design, measurement and standardization. Nevertheless, in a political climate which stresses service evaluation, measurable outcomes and empirical evidence, psychoanalytic psychotherapy must participate to survive. There may be gains from conducting research beyond simply meeting the requirement to provide evidence of effectiveness. Research may be viewed by some clinicians as an unwelcome intruder but it may have the potential to offer triangulation, the perspective of the ‘third’, and so strengthen the foundations of clinical practice and the development of psychoanalytic thought.     

Treatment manuals and the advancement of psychoanalytic knowledge: The Treatment Manual of the Tavistock Adult Depression Study

This paper has two aims: first, it seeks to understand the absence of treatment manuals in psychoanalysis. Secondly, it summarizes the treatment manual of the Tavistock Adult Depression Study, which describes the form of psychoanalytic psychotherapy whose effectiveness has been evaluated both in the Tavistock Adult Depression Study (TADS); and in the German Die Langzeittherapie bei chronischen Depressionen (LAC) Studie. Throughout the history of psychoanalysis, opinions about treatment manuals, empirical research and their antecedents have been deeply divided. After tracing the often polarized unfolding of these matters, the paper proposes that emotional and cognitive difficulties as well as scientific ones underpin their persistence. It is suggested that greater familiarity with them may lead to better combinations of outcome research and psychoanalysis: for example, the Tavistock manual seeks to match one account of the objects, aims, values, spirit and methods of psychoanalysis (as well as of connected forms of psychoanalytic psychotherapy); and also to meet what is required of treatment manuals by random allocation controlled trials. It has been a crucial element in the above studies of the outcome of long‐term psychoanalytic psychotherapies with chronically depressed patients. After describing the Tavistock Manual, the paper concludes suggesting that, if appropriately constructed, treatment manuals can make a contribution to the advancement of specifically psychoanalytic knowledge.     

An Attachment Perspective on Reunions in Couple Psychoanalytic Psychotherapy

Psychoanalysis has been slow to acknowledge attachment theory as one of its own. Yet traditions of observational and representational research associated with it have much to offer in shedding light on intrapsychic as well as interpersonal phenomena. This paper explores these traditions and their potential clinical utility for couple psychoanalytic psychotherapy. In particular, attention is drawn to behaviour and representations associated with the experience of reunion in therapy sessions.     

Can research influence clinical practice?1

After briefly reviewing the unfavourable reception accorded empirical research by parts of the psychoanalytic community, as well as some of the benefits to clinical practice of analysts being involved in research activities, the author examines whether the findings of process and outcome research in psychotherapy and psychoanalysis can help identify the most appropriate forms of intervention for producing therapeutic change, given the specific condition of the patient and the relationship that the individual establishes with the analyst. He argues that research findings can influence clinical practice on various levels and in different areas, and goes on to examine a number of related issues: the specificity of therapeutic interventions versus the relevance of common curative factors; the dyadic conception of technique and ways of understanding the therapeutic action of the treatment alliance; and the strategic or heuristic conception in psychoanalytic therapy. Finally, the author presents clinical material with the aim of illustrating how the knowledge acquired through research can be applied to psychoanalytic treatment.     

Optimizing Exposure Therapy for Pathological Health Anxiety: Considerations From the Inhibitory Learning Approach

Exposure therapy has demonstrated its efficacy in the treatment of pathological health anxiety—however, psychotherapy research reveals that many patients do not show a clinically significant change. Therefore, improvements are necessary to optimize psychotherapy for pathological health anxiety. Most treatment rationales refer to habituation during exposure as the central mechanism of change. However, there is evidence that extinction learning is mediated by inhibitory learning processes. Targeting these processes may help to improve treatment outcomes in pathological health anxiety. The aim of this review was to adapt, from the inhibitory learning approach and empirical findings, the most promising strategies for the exposure-based treatment of pathological health anxiety. The exposure-optimizing strategies adapted are expectancy violation, combination, variability in contexts and stimuli, affect labeling, and removal of safety signals. A case example illustrates how to implement these methods for patients with pathological health anxiety.     

Introducing an existential-phenomenological approach Part 2—theory for practice

Part one of this paper concentrated on phenomenological theory and research. This second section seeks to describe how existential-phenomenological therapy developed, and how the concepts apply in sessions. This direction for therapy could be called making conscious the preconscious, in the production of new information by reinterpreting the same scenes and experiences. This approach is compared to the psychoanalytic style of working. The existential-phenomenological approaches of Binswanger, Boss and Sartre, three key existential writers, are briefly mentioned, each of which evolved from the work of Husserl, Heidegger and Freud. But much detail is omitted in the aim of providng a succinct overview. This paper shows part of the sources of counselling and humanistic psychotherapy in the existential critique of psychoanalysis.     

Dynamic interpersonal therapy in an NHS tertiary level specialist psychotherapy service

We describe the introduction of dynamic interpersonal psychotherapy (DIT) into an National Health Service (NHS) tertiary psychoanalytic specialist psychotherapy service. Training in DIT began as our contribution to Improving Access to Psychological Therapies and primary care services, supporting the training and supervision of their DIT practitioners. We then discovered DIT could be a valuable treatment within our own tertiary NHS service for patients with complex presentations. Currently fighting for survival, like many NHS psychoanalytic psychotherapy services nationally, we have adopted a manual-guided, psychoanalytically based therapy to broaden our tertiary clinical psychoanalytic service and accommodate trends in mental health service provision, whilst protecting the quality and integrity of our psychotherapy. DIT helped us continue providing relevant and beneficial psychoanalytic and psychodynamic services to individual patients despite limitations of the financially challenged NHS, NICE guidelines and Payment by Results. We outline the progress and outcomes for patients with complex mental health presentations, include individual case discussion and our experience of using the DIT approach within a traditionally longer term psychoanalytic psychotherapy service.     

Rapprochement in Sight? Postmodern Family Therapy and Psychoanalysis

This paper explores aspects of the theory and practice of psychotherapy with the aim of identifying similarities in the approaches of both family therapists and psychoanalytic psychotherapists. The author calls for a dialogue between the disciplines, and makes specific reference to the potential value of this in relation to training and research.     

A training analysis for psychoanalytic psychotherapists

For historical reasons, psychoanalytic psychotherapy has been regarded as a second-class treatment in comparison with psychoanalysis, and standards for training in it have lagged behind those for psychoanalysis. However, psychoanalytic psychotherapy is the treatment of choice for many healthier (or higher-level) patients who cannot receive analysis for any reason, and also for a large population of more-disturbed patients who are not appropriate for psychoanalysis. Mastering techniques of psychoanalytic psychotherapy may be as difficult as mastering those of psychoanalysis, and should require comparable theoretical training, supervision, and personal treatment. This "development lag" in the training of psychoanalytic psychotherapists has taken place for several reasons: (1) Psychoanalytic ideas first emerged in America in the context of a new movement toward an electric, but dynamic psychiatry from which psychoanalysis had to establish its separate identity. (2) Psychotherapy was associated with techniques of suggestion and manipulation from which psychoanalysis wished to separate. (3) Because psychotherapy was seen as an inferior form of therapy which required little training, institutes were slow in being established, and reluctant to require a "training analysis." It is suggested that with the full training of psychoanalytic psychotherapists, this discipline may be regarded as a profession comparable to psychoanalysis. It is further suggested that the optimal treatment for the full training of the psychoanalytic psychotherapist is psychoanalysis, and that a "training psychotherapy" is not an adequate substitute, but may provide a transitional step to resolve initial resistances and to prepare the therapist for a training analysis.     

Approaches to evaluation

This paper offers some informal thoughts about audit and research studies in a psychotherapy or counselling context, drawing on the author's background in a difficult area of evaluation: the outcomes of psychoanalytic psychotherapy for children and adolescents. Reasons for therapists' difficulties with the idea of evaluation studies are considered, and possible designs for feasible research projects are briefly discussed. Examples of different strategies within one area are given, to illustrate the way in which different approaches can be patched together to yield important findings, and to overcome the limitations of any one approach. the place of audit in relation to research is also briefly discussed.