Clinical significance and patients' perceived change in four sessions of brief psychodynamic intervention: Characteristics of early responders

This study investigated Tingey, Lambert, Burlingame, and Hansen's (1996) extension of Jacobson, Follette and Revenstorf's (1984) proposal for assessing clinical significance. Seventy (N=70) outpatients with/without Cluster C personality disorders treated with a brief psychodynamic intervention (BDI) were included in the study. Results showed that 33% of patients demonstrated clinically significant change on the Global Severity Index. Patients who improved reported more perceived subjective change, greater satisfaction with the treatment, and greater improvement on the Social Adjustment Scale than patients who did not improve (60%) or deteriorated (7%). Further analyses showed that clinical significance achieved in a four session ultra‐brief therapy is associated with patient characteristics such as co‐morbid personality disorders, level of defensive functioning, and specific interpersonal problems. Results were maintained at 3 month and 6 month follow‐ups. Findings are discussed in reference to Howard's suggestions on remoralization and remission.     

Psychodynamic technique early in treatment related to outcome for depressed patients

We examined the relationship between psychodynamic techniques early in treatment with reliable change in depressive symptomatology. Forty‐six patients admitted for individual psychodynamic psychotherapy who received a diagnosis representative of a depressive spectrum disorder were assessed pretreatment and posttreatment through self‐report of depressive symptoms. Videotapes from two early treatment sessions (3rd and 9th) were independently rated on the Comparative Psychotherapy Process Scale for use of psychodynamic‐interpersonal and cognitive–behavioural techniques, with excellent interrater reliability (intraclass correlation coefficient > .75). We found a significant relationship between overall use of psychodynamic technique across early treatment (r = .31, p = .036), as well as specific psychodynamic techniques delivered across early treatment, with change in patient‐reported depressive symptoms. Our findings suggest that focusing on affective experiencing and expression, as well as providing interpretations are particularly helpful early in psychodynamic treatment for depression. Clinical implications and future directions are discussed.     

A comparison of dose-response curves in cognitive-behavioral and psychodynamic psychotherapies

Changes in patient- and therapist-rated process items, and patient-rated symptom severity assessed over a maximum of 30 sessions of psychodynamic or cognitive-behavioral psychotherapy were compared in an outpatient mental-health clinic. Patients' ratings in psychodynamic psychotherapy on two of the process items were superior to ratings by patients in cognitive-behavioral therapy, and interactions with time were discovered for an interpersonal item. Comparisons between patients who reported their initial symptom severities as most severe and those with less severe symptoms also were made, with results indicating differential effects of treatment according to perceptions of symptom severity. Interactions between length of stay in treatment and number of sessions also were investigated. Findings indicated that patients benefit from psychotherapy over time and support the usefulness of a contextual model for psychotherapy funding.     

Psychiatric morbidity and treatment pathway outcomes of patients presenting to specialist NHS psychodynamic psychotherapy services: Results from a multi‐centre study

Objective. Little is known about socio‐demographic, diagnostic, and clinical characteristics of patients referred for assessment to psychodynamic psychotherapy services. The aim of this study was to remedy this by prospectively collecting comprehensive and systematic demographic and clinical information on a large number of patients referred to NHS psychodynamic psychotherapy services. Design. Fourteen psychotherapy services operating within a National Health Service joined the study and contributed data for 1,136 patients referred from primary and secondary care clinics. Method. Patients were assessed using questionnaires and self‐rated measures, which included the clinician‐based version of the diagnostic form of the Millon clinical multi‐axial inventory‐III‐revised edition (MCMI‐III‐R), the brief symptom inventory (BSI), the inventory of interpersonal problems (IIP), and the clinical outcome in routine evaluation (CORE). The pathway from assessment through to treatment and variables associated with treatment uptake and exclusion are described and examined. Results. Most patients were in the moderate to severe range of psychiatric severity at the time of presentation. Ninety‐five percent met clinically based criteria for a psychiatric disorder (mostly anxiety and mood disorders) and/or personality disorder. Although the majority of patients were found suitable for treatment (N=935, 82%), analysis of uptake showed relatively high rates of treatment rejection by patients and treatment drop‐out. Partial outcome data at 6‐month follow‐up after intake into treatment revealed significant change but modest effect size (d=0.35). Conclusion. Systematic collection of baseline and outcome data would provide a national database of the performance of psychotherapy services that would be invaluable in facilitating comparative studies.     

A pilot study of psychodynamic psychotherapy for adult survivors of childhood sexual abuse

Clinical samples of child sexual abuse survivors report a variety of psychiatric symptoms and interpersonal difficulties. The treatment outcome literature for this population is often incomplete due to numerous methodological constraints. The purpose of this study was to evaluate the effectiveness of an open trial of individual short‐term, psychodynamic psychotherapy with a naturalistic sample of adult survivors of childhood sexual abuse. Sexual abuse survivors demonstrated significant improvement in symptomatic distress, level of functioning and dynamic personality variables according to self‐report measures and clinical rating scales. Abuse survivors developed positive therapeutic alliances, which remained high throughout the course of treatment, and comparable to the non‐abused clinical sample. Sexual abuse survivors' response to treatment was similar to that of non‐abused patients, with the potential for greater change in feelings about the self. These findings demonstrate that psychodynamic psychotherapy may be useful for childhood sexual abuse survivors presenting with depressive symptoms and interpersonal difficulties. Copyright © 2004 John Wiley & Sons, Ltd.     

A Psychodynamic Perspective on a Systematic Review of Online Psychotherapy for Adults

A variety of new psychotherapy modalities has arisen in which the contact between patient and therapist takes place via the internet. The main objective of this systematic review is to investigate the types of online psychotherapy (OP) conducted nowadays, and to describe their main characteristics to psychodynamic psychotherapists who may wish to better understand the current scientific literature on the subject. The review used two databases, EMBASE and PsycINFO. Fifty‐nine studies were retrieved and the main online psychotherapy modalities identified were self‐therapy programmes using contact via email or chat; videoconference; and therapy exclusively via chat or email. The result of these studies suggests that OP is more effective than a waiting list control group. When compared with face‐to‐face therapies, OP showed similar effects. Most studies involved cognitive behavioural therapy; only two studies involved a form of psychodynamic psychotherapy. Different forms of communication allow patient and therapist to establish different relationships and therapeutic possibilities. OPs may be feasible treatment alternatives; however, it remains unclear, especially in relation to psychodynamic treatments, if therapeutic technique in OP, which involves changes in comparison with face‐to‐face therapies, would be useful in severe cases. Psychodynamic psychotherapists should adopt a posture of constant reflection on the changes taking place in the world and their impact on the minds of individuals, without, nevertheless, idealizing the ‘new’.     

Who can benefit from time‐limited dynamic psychotherapy? A study of psychiatric outpatients with personality disorders

Introduction: This study examined whether measures of Personality Disorder (PD) from the Diagnostic and Statistical Manual of Mental Disorder IV, psychodynamic character, psychological mindedness, interpersonal patterns and personality traits predicted treatment outcome for PD patients. Method: Consecutive PD patients were randomly assigned to manualized time‐limited supportive‐expressive psychotherapy (SEP; n = 76) or non‐manualized open‐ended community delivered psychodynamic treatment (CDPT; n = 80). Significant predictors were tested together in order to examine whether they moderated or predicted the reduction of psychiatric symptoms (Symptom Check List‐90). Results: In the entire sample, patients with more severe levels of PD disorderness (number of positive PD criteria) had slower rates of improvement, but patients with more severe levels of vindictiveness (assessed by the Inventory of Interpersonal Problems [IIP]) had higher rates of improvement. High levels of IIP dominance were significantly related to higher rate of improvement in the CDPT treatment compared with SEP. Conclusion: Due to the fact that more severe PD patients had slower rates of improvement, longer treatment may be needed for this population. Specific interpersonal problems may impact whether patients should receive manualized or non‐manualized treatment. Copyright © 2007 John Wiley & Sons, Ltd.     

Long‐term outcome and post‐treatment effects of psychoanalytic psychotherapy with young adults

Objectives. The short‐ and long‐term effects of open‐ended, long‐term psychoanalytic psychotherapy for young adults were investigated. Possible changes during the year and a half follow‐up, as well as predictors of change, were explored. Design. Patients aged 18–25 years who accepted the offered psychoanalytic individual or group psychotherapy were included. Patients filled out questionnaires and were interviewed at intake, termination, and follow‐up. Alliance data were collected after the second session of psychotherapy proper. Methods. The primary outcome measures were the Symptom Checklist‐90 and the Inventory of Interpersonal Problems. The Helping Alliance Questionnaire‐II was used to measure alliance. Mixed model ANOVAs were used to analyse changeover time and prediction of change in relation to gender, treatment format, treatment duration, and in individual psychotherapy, therapist‐ and patient‐rated alliance. Results. All outcome measures changed significantly from intake to follow‐up. None changed significantly during the follow‐up period, but there was a tendency towards recurring symptoms and an improvement in one of the object relational measures during the follow‐up. The latter was the only outcome measure that did not change significantly during treatment. Lower therapist‐rated alliance was predictive of greater change in psychiatric symptoms for patients with high levels of symptoms at intake. Conclusions. The long‐term effectiveness of psychoanalytic psychotherapy for young adults was supported. Low therapist‐rated alliance implies that the therapists have identified problematic interactions, which might have mobilized their effort to solve the problems. Further research on cases reporting no gain or even deterioration is needed.     

Course of improvement over 2 years in psychoanalytic and psychodynamic outpatient psychotherapy

Objective. To assess and predict the level and course of symptomatic improvement in psychoanalytic (PAP) and psychodynamic psychotherapy (PD). Methods. In a comprehensive longitudinal study, the course of improvement of 116 patients in PAP and of 357 patients in PD was tracked over a period of 2 years and analysed via hierarchical linear models. Results. At baseline, over 90% of the patients reported substantial psychological, physical or interpersonal distress. In both forms of treatment, the course of improvement could be adequately fitted by a linear model. Symptom distress decreased notably within 2 years, with an especially sharp decline before the first formally scheduled therapy session. 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 2‐year observation period with those with still ongoing treatments, the former showed quicker symptom improvement. Discussion. Strategies for the optimal allocation of valuable therapeutic resources should be reconsidered. An adaptive, outcome‐oriented allocation strategy of therapeutic resources is proposed.     

Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up

BACKGROUND: Insufficient evidence exists for a viable choice between long- and short-term psychotherapies in the treatment of psychiatric disorders. The present trial compares the effectiveness of one long-term therapy and two short-term therapies in the treatment of mood and anxiety disorders. METHOD: In the Helsinki Psychotherapy Study, 326 out-patients with mood (84.7%) or anxiety disorder (43.6%) were randomly assigned to three treatment groups (long-term psychodynamic psychotherapy, short-term psychodynamic psychotherapy, and solution-focused therapy) and were followed up for 3 years from start of treatment. Primary outcome measures were depressive symptoms measured by self-report Beck Depression Inventory (BDI) and observer-rated Hamilton Depression Rating Scale (HAMD), and anxiety symptoms measured by self-report Symptom Check List Anxiety Scale (SCL-90-Anx) and observer-rated Hamilton Anxiety Rating Scale (HAMA). RESULTS: A statistically significant reduction of symptoms was noted for BDI (51%), HAMD (36%), SCL-90-Anx (41%) and HAMA (38%) during the 3-year follow-up. Short-term psychodynamic psychotherapy was more effective than long-term psychodynamic psychotherapy during the first year, showing 15-27% lower scores for the four outcome measures. During the second year of follow-up no significant differences were found between the short-term and long-term therapies, and after 3 years of follow-up long-term psychodynamic psychotherapy was more effective with 14-37% lower scores for the outcome variables. No statistically significant differences were found in the effectiveness of the short-term therapies. CONCLUSIONS: Short-term therapies produce benefits more quickly than long-term psychodynamic psychotherapy but in the long run long-term psychodynamic psychotherapy is superior to short-term therapies. However, more research is needed to determine which patients should be given long-term psychotherapy for the treatment of mood or anxiety disorders.     

Change in patient affect/defense ratio from early to late sessions in brief psychotherapy

The current study examined changes in the ratio of patients' affective and defensive behaviors during the course of brief psychodynamic psychotherapy. Treatments of 16 patients were videotaped. For each patient, four sessions were evaluated with a minute-by-minute coding system of process variables. When patients were grouped according to outcome scores, significant differences between the high outcome and the average-to-low outcome groups emerged. During the early phase of treatment, patients in both groups showed an average of one affective response per five defensive responses. By the late phase of treatment, the high outcome patients showed a marked shift to one affective response per two defensive responses, while the low outcome patients remained the same. An incidental finding was a negative correlation between good outcome and the ratio of defensive behavior to total patient activity.     

Treatment intensity and regularity in early outpatient psychotherapy and its relation to outcome

The distribution of treatment sessions (number of interruptions, weeks without psychotherapy and number of sessions) during the first three months of psychodynamic psychotherapy (PD), cognitive behavioral therapy (CBT) and psychoanalytic psychotherapy (PAP) was analyzed prospectively over two years in a sample of 256 outpatients. Number of weeks without psychotherapy in early treatment was predicted by initial helping alliance in PD and by initial quality of interpersonal relations in CBT. Level of initial psychological or physical impairment showed no effect on distribution of sessions during early treatment. In PD and CBT, session distribution early in treatment did not predict subsequent course of improvement. Only in PAP did weeks without psychotherapy and number of sessions affect rate of symptom change, in that participants showed better outcome when treatment started continuously at a rather slow pace. Implications for psychotherapy practice and research are discussed. Copyright © 2006 John Wiley & Sons, Ltd.     

Longitudinal analysis of the relationship between symptoms and quality of life in veterans treated for posttraumatic stress disorder

This study examined how change in posttraumatic stress disorder (PTSD) symptoms relates to change in quality of life. The sample consisted of 325 male Vietnam veterans with chronic PTSD who participated in a randomized trial of group psychotherapy. Latent growth modeling was used to test for synchronous effects of PTSD symptom change on psychosocial and physical health-related quality of life within the same time period and lagged effects of initial PTSD symptom change on later change in quality of life. PTSD symptoms were associated with reduced quality of life before treatment. There were synchronous effects of symptom change on change in quality of life but no significant lagged effects. Results indicate the importance of measuring quality of life in future investigations of PTSD treatment.     

Drug addiction from a psychodynamic perspective: Methadone maintenance treatment (MMT) as transitional phenomena

Purpose. To present a psychodynamic (specifically object‐relations) approach to the understanding of drug addiction and recovery among patients in Methadone Maintenance Treatment (MMT), and to discuss the role of psychodynamic psychotherapy among drug addicts, focusing on the processes which patients undergo during counselling. Methods. We review some psychodynamic explanations of the drug addiction phenomenon, and illustrate the psychodynamic comprehension framework of the issue according to Winnicott's theory, by describing a few psychotherapeutic interventions with our MMT patients. Results. The main premise is that treatment in a MMT program is accompanied by changes in‐patients' life‐styles and behaviour, which are parallel to transitional phenomena. As such, methadone and counselling serve as transitional objects during these processes. Conclusions. Drug addiction is a widespread phenomenon that affects many areas in the addicts' life; therefore, some eclecticism from therapists has a beneficial effect on the outcome.     

Effectiveness of Day Hospital Mentalization‐Based Treatment for Patients with Severe Borderline Personality Disorder: A Matched Control Study

The present study extends the body of evidence regarding the effectiveness of day hospital Mentalization‐Based Treatment (MBT) by documenting the treatment outcome of a highly inclusive group of severe borderline personality disorder (BPD) patients, benchmarked by a carefully matched group who received other specialized psychotherapeutic treatments (OPT). Structured diagnostic interviews were conducted to assess diagnostic status at baseline. Baseline, 18‐month treatment outcome and 36‐month treatment outcome (after the maintenance phase) on psychiatric symptoms (Brief Symptom Inventory) and personality functioning (118‐item Severity Indices of Personality Problems) were available for 29 BPD patients assigned to MBT, and an initial set of 175 BPD patients assigned to OPT. Propensity scores were used to determine the best matches for the MBT patients within the larger OPT group, yielding 29 MBT and 29 OPT patients for direct comparison. Treatment outcome was analysed using multilevel modelling. Pre to post effect sizes were consistently (very) large for MBT, with a Cohen's d of −1.06 and −1.42 for 18 and 36 months, respectively, for the reduction in psychiatric symptoms, and ds ranging from 0.81 to 2.08 for improvement in domains of personality functioning. OPT also yielded improvement across domains but generally of moderate magnitude. In conclusion, the present matched control study, executed by an independent research institute outside the UK, demonstrated the effectiveness of day hospital MBT in a highly inclusive and severe group of BPD patients, beyond the benchmark provided by a mix of specialized psychotherapy programmes. Interpretation of the (large) between condition effects warrants cautionary caveats given the non‐randomized design, as well as variation in treatment dosages. Copyright © 2014 John Wiley & Sons, Ltd.     

The importance of reflective functioning to the diagnosis of psychic structure

Objective. This pilot study examines the connection between the concept of Fonagy and Target's reflective functioning and the structure axis of operationalized psychodynamic diagnostics (OPD) and assesses the potential of both scales to predict therapy success. Method. In the study, 24 (female) patients of the psychotherapy ward of the Frankfurt University Hospital for psychosomatic medicine and psychotherapy aged 18 to 55 were assessed on the basis of a 90‐minute, semi‐structured interview with regard to their capability for reflective functioning as well as with regard to their structural level according to OPD. In addition, the SCL‐90‐R was administered at the beginning and end of the 3‐month in‐patient therapy. Results. A significant correlation was found between reflective functioning and the structure axis of OPD. Reflective functioning also predicted improvement in overall mental condition through a 3‐month in‐patient therapy. This remained significant even when the influence of the overall assessment of structure according to OPD was removed. Conclusions. The independence of the concept of reflective functioning (RF) and its implications for the clinical stance are discussed.     

Mentalization‐based psychodynamic psychotherapy for psychosis

This article discusses and illustrates the use of mentalization‐based psychodynamic psychotherapy for disturbances of awareness of the self and others in patients with psychotic‐spectrum disorders. The literature on impairments of mental processes involved in self‐awareness and awareness of others occurring in psychotic illnesses and the relationship between childhood trauma and the emergence of psychotic symptoms is reviewed. A case illustrates how mentalization‐based treatment can facilitate treatment engagement and be used to manage enactments in the psychotherapy with a patient with a psychotic disorder. Mentalization‐based psychotherapy may offer a useful adjunct to antipsychotic medication and psychosocial evidence‐based treatments in the care of individuals in the early phase of psychotic disorders. © 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65:1–12, 2009.     

Psychopathology and well‐being in civilian survivors of war seeking treatment: a follow‐up study

The goal of the current study was to examine types of exposure to traumatic events and affective and anxiety disorders of 81 civilian war survivors seeking treatment for war‐related stress almost one decade following the war in the area of former conflict. Furthermore, the study investigated changes in symptoms of mental health and in well‐being amongst these individuals during a treatment period of 6 months. The results indicated that civilian war survivors seeking treatment reported multiple war‐related traumatic events and high levels of psychiatric morbidity. Individuals assessed at follow‐up (n = 67) reported no change in post‐traumatic stress symptoms or psychological well‐being, but improvement in symptoms of depression, overall psychiatric distress and quality of life. The only significant difference between participants classified as achieving clinically significant improvement as compared with those who did not achieve such change was in less symptom severity of depression, post‐traumatic stress, general distress and higher psychological well‐being at the time of first assessment. Neither the assessment of initial diagnoses nor war or post‐war trauma types emerged as significantly different amongst the two groups. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: ? Civilian survivors of war seeking treatment report high levels of psychiatric morbidity. ? Treatment for survivors of war may require adaptations to evidence‐based treatments based on their culture and life circumstances in order to recover from PTSD and experience general emotional relief.