Short-term dynamically oriented psychotherapy: A review and meta-analysis

Efficacy of dynamic interpersonal therapy for major depressive disorder in China: results of a multicentered, three-arm, randomized, controlled trial

BACKGROUND

Dynamic interpersonal therapy (DIT) is a brief, structured psychodynamic psychotherapy with demonstrated efficacy in treating major depressive disorder (MDD). The aim of the study was to determine whether DIT is an acceptable and efficacious treatment for MDD patients in China.

METHOD

Patients were randomized to 16-week treatments with either DIT plus antidepressant medication (DIT + ADM; n = 66), general supportive therapy plus antidepressant medication (GST + ADM; n = 75) or antidepressant medication alone (ADM; n = 70). The Hamilton Depression Rating Scale (HAMD) administered by blind raters was the primary efficacy measure. Assessments were completed during the acute 16-week treatment and up to 12-month posttreatment.

RESULTS

The group × time interaction was significant for the primary outcome HAMD (F = 2.900, df1 = 10, df2 = 774.72, p = 0.001) in the acute treatment phase. Pairwise comparisons showed a benefit of DIT + ADM over ADM at weeks 12 [least-squares (LS) mean difference = -3.161, p = 0.007] and 16 (LS mean difference = -3.237, p = 0.004). Because of the unexpected high attrition during the posttreatment follow-up phase, analyses of follow-up data were considered exploratory. Differences between DIT + ADM and ADM remained significant at the 1-, 6-, and 12-month follow-up (ps range from 0.001 to 0.027). DIT + ADM had no advantage over GST + ADM during the acute treatment phase. However, at the 12-month follow-up, patients who received DIT remained less depressed.

CONCLUSIONS

Acute treatment with DIT or GST in combination with ADM was similarly efficacious in reducing depressive symptoms and yielded a better outcome than ADM alone. DIT may provide MDD patients with long-term benefits in symptom improvement but results must be viewed with caution.

Mentalization-oriented psychodynamic group therapy for patients with personality disorders: a naturalistic prospective cohort study

OBJECTIVES

Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combines a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patients with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning.

METHODS

The design was a naturalistic, prospective cohort study. Seventy-five consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample was repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention.

RESULTS

Among completers (n = 42; 56%), improvement was observed on the SCL-90-R: Global Severity Index (mean change = -0.45 [95% CI = -0.72, -0.19]; Cohen's d = -0.55), Positive Symptom Distress Index (-0.40 [-0.63, -0.17]; -0.56); Positive Symptoms Total (-10.70 [-17.31, -4.09]; -0.52). Secondary outcomes also improved: IIP-total (mean change = -0.50 [95%CI = -0.74, -0.25]; Cohen's d = -0.66); GAF-Functioning (8.79 [6.32, 11.27]; 1.15); and GAF-Symptoms (10.67 [8.09, 13.25]; 1.34).

CONCLUSIONS

Completers improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that mentalization-oriented PDT spanning several years may be unrealistic for many patients with PD. Significant outcomesThere are no clear guidelines for psychological interventions targeting personality disorders (PDs), and currently eclectic and non-manualized psychodynamic approaches lasting for up to 3 years are prevailing in some clinical practices.Although this treatment approach may have an effect on compliant patients, the high drop-out rate indicates that it may not be suitable for a large proportion of PD patients since it requires long-term commitment. Furthermore, it is difficult to identify the content of the non-manualized psychodynamic therapy and what helps the patients.More specific clinical guidelines emphasizing the application of evidence-based treatments or at least manualized treatments are warranted for the treatment of emotionally unstable PDs and other PDs. LimitationsThe naturalistic study design, without any control group, limits conclusions about mechanisms of action of the intervention.Since the intervention was not manualized, it is unknown exactly which treatment was actually administered, which reduces external validity.The outcomes are based on completer data of a relatively small sample size with high drop-out rate.

A Psychoanalytic-Derived Brief Psychotherapeutic Approach in the Treatment of Major Depression: Monotherapy Studies

Over the years, short term psychodynamic therapy (STPP) has been broadly researched in order to evaluate its efficacy in the treatment of major psychiatric disorders. In particular, a consistent number of studies focused on assessing clinical outcomes of the principal psychodynamic techniques in treating depressive disorders. We conducted a narrative review in which we aimed to evaluate the efficacy of STPP in monotherapy in major depressive disorder and to assess possible features that may correlate with its clinical use. Databases searched were PubMed, Ovid, Scopus, PsycINFO and Cochrane Libraries from inception to July 2022. Our research underlined that STPP in monotherapy is particularly effective in moderately severe depression and in preventing depressive relapses. Moreover, a case-by-case evaluation of its efficacy should be performed when considering STPP for the treatment of major depression with other comorbid psychiatric conditions. Although such key points emerged from scientific evidence, STPP should be better studied in the long-term perspective; further research is needed to define the clinical scenarios in which STPP can be considered a first-line approach as monotherapy in major depressive disorder compared to medications or other types of psychotherapy.

Mechanisms of Change in Intensive Short-Term Dynamic Psychotherapy: Systematized Review

OBJECTIVE

Despite increasing evidence for the effectiveness of intensive short-term dynamic psychotherapy (ISTDP), evidence supporting the purported mechanisms of change in ISTDP is lacking. This systematized review aimed to describe the major theorized mechanisms of change in ISTDP, critically evaluate the emerging literature pertaining to its purported mechanisms, and explore directions for future research.

METHODS

A systematized search of the literature was conducted by using online databases (PsychInfo, PubMed, EMBASE, and CINAHL).

RESULTS

Fourteen studies met inclusion criteria. The included studies explored at least one theorized ISTDP mechanism of change and attempted to operationalize or otherwise empirically examine the mechanism in relation to the therapeutic process. Examined mechanisms included "unlocking the unconscious" and specific therapist interventions.

CONCLUSIONS

The current body of literature has several limitations, most notably the lack of a consensus definition for unlocking the unconscious. This difficulty in measuring mechanisms of change is common across therapeutic modalities and limits the validity and comparability of findings. Despite these limitations, the literature suggests a possible association between theorized mechanisms of change and positive therapy outcomes. Future research directions are discussed.

Efficacy of brief dynamic interpersonal therapy in patients with major depressive disorder: a prospective, multicenter randomized controlled trial protocol

BACKGROUND

In China, psychodynamic psychotherapies are widely used as a treatment for depression. However, very few efficacy studies of psychodynamic therapies have been conducted with the Chinese population. This paper describes a study protocol of a multicenter randomized controlled trial of dynamic interpersonal psychotherapy (DIT), a brief manualized depression-focused intervention, in Chinese adults with major depressive disorder (MDD).

METHODS

Recruitment is planned in five hospitals. Two hundred forty patients with MDD will be randomly allocated on a 1:1:1 basis to either medication plus DIT, medication plus an active control psychotherapy, or medication alone. Patients will be assessed at baseline and at weeks 2, 4, 8, 12, and 16 during the acute treatment phase and 1, 3, 6, and 12 months posttreatment. The primary outcome is change from baseline in the 17-item Hamilton Depression Rating Scale, administered by independent raters who are blind to treatment allocation. The Hamilton Anxiety Rating Scale, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, response, remission and relapse rates, self-assessment of overall efficacy and satisfaction of patients, and side effect profiles are secondary measures.

DISCUSSION

This will be the first multicentered RCT in China to assess the efficacy of a brief psychodynamic intervention for MDD. The study has the potential to inform clinical treatment guidelines for the treatment of depression in China.

TRIAL REGISTRATION

ChiCTR, ChiCTR1800016970 . Registered on July 5, 2018.

An intervention for parents with severe personality difficulties whose children have mental health problems: a feasibility RCT

BACKGROUND

The children of parents with severe personality difficulties have greater risk of significant mental health problems. Existing care is poorly co-ordinated, with limited effectiveness. A specialised parenting intervention may improve child and parenting outcomes, reduce family morbidity and lower the service costs.

OBJECTIVES

To develop a specialised parenting intervention for parents affected by severe personality difficulties who have children with mental health problems and to conduct a feasibility trial.

DESIGN

A pragmatic, mixed-methods design to develop and pilot a specialised parenting intervention, Helping Families Programme-Modified, and to conduct a randomised feasibility trial with process evaluation. Initial cost-effectiveness was assessed using UK NHS/Personal Social Services and societal perspectives, generating quality-adjusted life-years. Researchers collecting quantitative data were masked to participant allocation.

SETTING

Two NHS mental health trusts and concomitant children's social care services.

PARTICIPANTS

Parents who met the following criteria: (1) the primary caregiver of the index child, (2) aged 18-65 years, (3) have severe personality difficulties, (4) proficient in English and (5) capable of providing informed consent. Index children who met the following criteria: (1) aged 3-11 years, (2) living with index parent and (3) have significant emotional/behavioural difficulties. Exclusion criteria were (1) having coexisting psychosis, (2) participating in another parenting intervention, (3) receiving inpatient care, (4) having insufficient language/cognitive abilities, (5) having child developmental disorder, (6) care proceedings and (7) index child not residing with index parent.

INTERVENTION

The Helping Families Programme-Modified - a 16-session intervention using structured, goal-orientated strategies and collaborative therapeutic methods to improve parenting, and child and parent functioning. Usual care - standard care augmented by a single psychoeducational session.

MAIN OUTCOME MEASURES

Trial feasibility - rates of recruitment, eligibility, allocation, retention, data completion and experience. Intervention acceptability - rates of acceptance, completion, alliance (Working Alliance Inventory-Short Revised) and experience. Outcomes - child (assessed via Concerns About My Child, Eyberg Child Behaviour Inventory, Child Behaviour Checklist-Internalising Scale), parenting (assessed via the Arnold-O'Leary Parenting Scale, Kansas Parental Satisfaction Scale), parent (assessed via the Symptom Checklist-27), and health economics (assessed via the Client Service Receipt Inventory, EuroQol-5 Dimensions).

RESULTS

The findings broadly supported trial feasibility using non-diagnostic screening criteria. Parents were mainly referred from one site (75.0%). Site and participant factors delayed recruitment. An estimate of eligible parents was not obtained. Of the 86 parents referred, 60 (69.7%) completed screening and 48 of these (80.0%) were recruited. Participants experienced significant disadvantage and multiple morbidity. The Helping Families Programme-Modified uptake (87.5%) was higher than usual-care uptake (62.5%). Trial retention (66.7%, 95% confidence interval 51.6% to 79.6%) exceeded the a priori rate. Process findings highlighted the impact of random allocation and the negative effects on retention. The Helping Families Programme-Modified was acceptable, with duration of delivery longer than planned, whereas the usual-care condition was less acceptable. At initial follow-up, effects on child and parenting outcomes were detected across both arms, with a potential outcome advantage for the Helping Families Programme-Modified (effect size range 0.0-1.3). For parental quality-adjusted life-years, the Helping Families Programme-Modified dominated usual care, and child quality-adjusted life-years resulted in higher costs and more quality-adjusted life-years. At second follow-up, the Helping Families Programme-Modified was associated with higher costs and more quality-adjusted life-years than usual care. For child quality-adjusted life-years, when controlled for baseline EuroQol-5 Dimensions, three-level version, usual care dominated the Helping Families Programme-Modified. No serious adverse events were reported.

CONCLUSION

The Helping Families Programme-Modified is an acceptable specialised parenting intervention. Trial methods using non-diagnostic criteria were largely supported. For future work, a definitive efficacy trial should consider site selection, recruitment methods, intervention efficiency and revised comparator condition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14573230.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 14. See the NIHR Journals Library website for further project information.

Psychoanalytic and psychodynamic therapies for depression: the evidence base

This article argues that the current approach to guideline development for the treatment of depression is not supported by the evidence: clearly depression is not a disease for which treatment efficacy is best determined by short-term randomised controlled trials. As a result, important findings have been marginalised. Different principles of evidence-gathering are described. When a wider range of the available evidence is critically considered the case for dynamic approaches to the treatment of depression can be seen to be stronger than is often thought. Broadly, the benefits of short-term psychodynamic therapies are equivalent in size to the effects of antidepressants and cognitive–behavioural therapy (CBT). The benefits of CBT may occur more quickly, but those of short-term psychodynamic therapies may continue to increase after treatment. There may be a ceiling on the effects of short-term treatments of whatever type. Longer-term psychodynamic treatments may improve associated social, work and personal dysfunctions as well as reductions in depressive symptoms.

The Güttingen study of psychoanalytic therapy: First results

Results of a naturalistic study of the effectiveness of psychoanalytic therapy are reported. Outcome data are presented for a sample of N = 36 patients who were treated with psychoanalytic therapy. For a sample of n = 23 of these patients, data for 1-year follow-up are available at present. According to the results, psychoanalytic therapy yielded significant improvements in symptoms (Symptom Checklist 90-R, SCL-90-R and rating of psychoanalysts), in interpersonal problems (Inventory of Interpersonal Problems, IIP), in quality of life (Questionnaire of Quality of Life, FLZ), in well-being (Questionnaire of Changes in Experience and Behaviour VEV) and in target problems defined by the patients (Goal Attainment Scaling, GAS). Large effect sizes between 1.28 and 2.48 were found in symptoms (GSI of the SCL-90-R), interpersonal problems (IIP-total), quality of life (FLZ-total), well-being (VEV) and target problems (GAS). At 1-year follow-up, all improvements proved to be stable or even increased. The self-reported improvements in symptoms were corroborated by the ratings of the psychoanalysts. At the end of therapy, 77% of the patients showed clinically significant improvements. In the 1-year follow-up group, this was true for 80%. Further results are presented and discussed.

Psychodynamic Treatment of Combat Veterans with PTSD at Risk for Suicide

Posttraumatic stress disorder is a condition associated with suicide in both military personnel and combat veterans. Most veterans with PTSD, however, are not at risk of suicide. The major factor distinguishing those who attempted or were preoccupied with suicide is persistent severe guilt over behavior in combat while emotionally out of control. A 12-session short-term, psychodynamic psychotherapy, presented here, showed promise of success in dissipating the guilt from combat-related actions in veterans of the war in Vietnam. Preliminary work with combat veterans of the wars in Iraq and Afghanistan indicates it may be equally successful in treating them. Basic aspects of the psychodynamic approach could also be incorporated into current therapies and should improve their ability to treat veterans with PTSD at risk for suicide. Case examples are provided.

“Winter Is Coming!”—Treatment of Obsessive-Compulsive Disorder Imagery After Viewing the Television Series Game of Thrones

This article presents the detailed case of a 27-year-old man who began to suffer from intrusive imagery after watching a brutal scene in the TV series Game of Thrones. The content of the intrusive imagery included images of people with enucleated eyes and was initially accompanied by anxiety about sharp objects. The patient’s mental distress was assessed by the Yale-Brown Obsessive Compulsive Scale and the Impact of Event Scale—Revised, and the patient was diagnosed with obsessive-compulsive disorder (OCD). Eye movement desensitization and reprocessing (EMDR) therapy was provided to treat related distressing memories and the intrusive imagery. As treatment progressed, more complex and layered aspects of the symptom presentation became evident, and EMDR was integrated with other treatments. These included psychodynamic psychotherapy to address his complicated relationship with his father, exposure and response prevention (ERP) therapy to reduce avoidance of sharp objects, and cognitive therapy (CT) for aggressive violent thoughts toward others. The article identifies the various clinical decision points and discusses theoretical conceptualizations and related factors. This clinical case report provides additional support for the body of knowledge on the relationship between traumatic events and imagery in OCD. Therefore, trauma-focused treatments, such as EMDR therapy, which concentrates specifically on those experiences, might be especially effective.

Changes in the Interpersonal Characteristics of a Client Who “Recovered” From Anxiety and Depression Following Interactionist Interpersonal Therapy

This therapeutic approach assumes that for successful outcome, changes in clients' interpersonal patterns are necessary. This client, “Helen,” presented with symptoms of anxiety and depression. After 45 sessions, she had made clinically significant improvement in these symptoms. Based on our case formulation, specific interpersonal characteristics were identified as targets for change (i.e., to move from being hostile and distant as her predominant interpersonalpatternto beingmore affiliative and assertive). Onthe basis of scores on three different interpersonal circumplex instruments taken over the course of the 45 sessions, the changes were consistently in line with the targeted interpersonal characteristics. The therapist was able to respond to Helen's hostile, distant pattern with non-controlling friendly acceptance and with a focus on her internal experiences, which promoted a strong therapeutic bond. Contributions to the outcome of this specific approach in conjunction with common factors are discussed.

Short-term Dynamic Psychotherapy versus Sertraline in Treatment of Social Phobia

Background:

A few studies on short-term psychodynamic approach have been conducted on social phobia.

Objectives:

In this study, the effectiveness of short-term psychodynamic psychotherapy on the treatment of social phobia has been compared to the effectiveness of sertraline and waiting list.

Materials and Methods:

In this randomized-controlled trial study, 13 male students were treated with short-term dynamic psychotherapy (McCullough method) lasting 25 sessions, 11 students received sertraline for 12 weeks, and 14 students, as the waiting list, received no intervention for 8 weeks. Participants completed the Social Phobia Inventory (SPIN) as primary efficacy variable 4 times, and were rated with Clinical Global Impression scale (CGI) and Global Assessment of Functioning (GAF) as secondary efficacy variables. The data were analyzed with analysis of variance (ANOVA), analysis of covariance (ANCOVA), general linear model repeated measures analysis of variance and Fisher exact test.

Results:

ANCOVA showed significant differences between groups based on SPIN scores (F = 23.51, Sig. = 0.001) and Bonferroni test, as post hoc compression, showed means of both short-term dynamic therapy and sertraline therapy groups were significantly different from waiting list mean (STDP-WL: x̅dif = 15.76, Sig. = 0.001), (MED-WL: x̅ = 15.91, Sig. = 0.001). Mean of SPIN scores was not significantly different between short-term dynamic psychotherapy and pharmacotherapy groups. In both treatment groups, means of SPIN scores significantly decreased in posttest, but not in waiting. These results repeated with GAF and CGI scores.

Conclusions:

The results indicated that short-term dynamic psychotherapy sertraline are effective in decreasing social phobia symptoms and were superior to control group.

Short-term psychodynamic psychotherapies for common mental disorders

BACKGROUND

Since the mid-1970s, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders have been developed and studied. Early published meta-analyses of STPP, using different methods and samples, have yielded conflicting results, although some meta-analyses have consistently supported an empirical basis for STPP. This is an update of a review that was last updated in 2006.

OBJECTIVES

To evaluate the efficacy of STPP for adults with common mental disorders compared with wait-list controls, treatments as usual and minimal contact controls in randomised controlled trials (RCTs). To specify the differential effects of STPP for people with different disorders (e.g. depressive disorders, anxiety disorders, somatoform disorders, mixed disorders and personality disorder) and treatment characteristics (e.g. manualised versus non-manualised therapies).

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) was searched to February 2014, this register includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also conducted searches on CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, DARE and Biological Abstracts (all years to July 2012) and all relevant studies (identified to 2012) were fully incorporated in this review update. We checked references from papers retrieved. We contacted a large group of psychodynamic researchers in an attempt to find new studies.

SELECTION CRITERIA

We included all RCTs of adults with common mental disorders, in which a brief psychodynamic therapy lasting 40 or fewer hours in total was provided in individual format.

DATA COLLECTION AND ANALYSIS

Eight review authors working in pairs evaluated studies. We selected studies only if pairs of review authors agreed that the studies met inclusion criteria. We consulted a third review author if two review authors could not reach consensus. Two review authors collected data and entered it into Review Manager software. Two review authors assessed and scored risk of bias. We assessed publication bias using a funnel plot. Two review authors conducted and reviewed subgroup analyses.

MAIN RESULTS

We included 33 studies of STPP involving 2173 randomised participants with common mental disorders. Studies were of diverse conditions in which problems with emotional regulation were purported to play a causative role albeit through a range of symptom presentations. These studies evaluated STPP for this review's primary outcomes (general, somatic, anxiety and depressive symptom reduction), as well as interpersonal problems and social adjustment. Except for somatic measures in the short-term, all outcome categories suggested significantly greater improvement in the treatment versus the control groups in the short-term and medium-term. Effect sizes increased in long-term follow-up, but some of these effects did not reach statistical significance. A relatively small number of studies (N < 20) contributed data for the outcome categories. There was also significant heterogeneity between studies in most categories, possibly due to observed differences between manualised versus non-manualised treatments, short versus longer treatments, studies with observer-rated versus self report outcomes, and studies employing different treatment models.

AUTHORS' CONCLUSIONS

There has been further study of STPP and it continues to show promise, with modest to large gains for a wide variety of people. However, given the limited data, loss of significance in some measures at long-term follow-up and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.

The effectiveness of solution-focused therapy and short- and long-term psychodynamic psychotherapy on self-concept during a 3-year follow-up

This study compares the effectiveness of solution-focused therapy (SFT) and short- and long-term psychodynamic psychotherapy (SPP and LPP) on self-concept during a 3-year follow-up. Altogether, 326 patients with mood or anxiety disorder were randomized to SFT, SPP, and LPP in the Helsinki Psychotherapy Study. Outcome was assessed using the Structural Analysis of Social Behavior questionnaire at baseline and 7, 12, 24, and 36 months after. Overall, during the first year of follow-up, self-concept improved more in both SFT and SPP than in LPP, indicated by the primary outcome indicators self-directed affiliation (AF) and self-directed autonomy, as well as by most of the eight secondary cluster scores. After the 3-year follow-up, LPP was more effective than SFT in AF and in the cluster scores self-affirm, self-blame, and self-neglect, whereas no difference was noted between LPP and SPP. Long duration and psychodynamic orientation of therapy may be beneficial for self-concept improvement.

Short-Term Psychodynamic Psychotherapy for personality disorders: a critical review of randomized controlled trials

The research evidence for Short-Term Psychodynamic Psychotherapy (STPP) in the treatment of personality disorders (PD) was examined through consideration of studies utilizing randomized controlled designs. An extensive literature search revealed eight published Randomized Controlled Trials (RCT) of moderate study quality. A critical review of this literature is offered to provide an evidence-based guidance for clinicians and implications for treatments are discussed. Preliminary conclusions suggest STPP may be considered an efficacious empirically-supported treatment option for a range of PDs, producing significant and medium to long-term improvements for a large percentage of patients. Further research is recommended to allow comparisons with alternative evidence-based approaches.

Toward a tripartite vision of supervision for psychoanalysis and psychoanalytic psychotherapies: alliance, transference-countertransference configuration, and real relationship

The psychoanalytic supervision relationship is examined as a tripartite phenomenon, comprised of the supervisory alliance, transference-countertransference configuration, and real relationship. While most supervisory analysts would readily acknowledge that a real (or personal) relationship element exists in analytic supervision, that facet of the supervision relationship has not routinely been incorporated into considerations of psychoanalytic supervision. In this vision of supervision, real relationship, supervisory alliance, and transference-countertransference configuration are presented as integral and complementary constructs that define psychoanalytic supervision. Each of those three components is examined briefly with regard to its beginnings, evolution, and contemporary status; each component is also considered from an empirical perspective. While we have a growing quantitative and qualitative research foundation that supports psychoanalytic practice, psychoanalytic supervision has largely been ignored as a subject and object of scientific study. Supervisory alliance, transference-countertransference configuration, and real relationship are explored as research ready variables. Some clinical hypotheses--eminently testable and worthy of investigation--are proposed with regard to each component of the model, and some ideas--albeit tentative and preliminary--about how to initiate such inquiries are offered.

The psychodynamic diagnostic manual: an effort to compensate for the limitations of descriptive psychiatric diagnosis

This article describes, from the perspective of a participant in the process, the background of and rationale for the development of the Psychodynamic Diagnostic Manual (PDM), a classification system based on both long-standing clinical observation and recent empirical research. It was hoped that the PDM would compensate for some of the unintended negative consequences to practitioners and their clients of uncritical reliance on descriptive psychiatric taxonomies such as the Diagnostic and Statistical Manual of the American Psychiatric Association. A shared and motivating experience of the contributors to the PDM was dismay at how the dominance of a narrow, descriptive-psychiatry model has promoted the decline of the empirically sound and clinically valuable idiographic tradition, in which clients' difficulties are conceptualized in the context of their unique personalities, developmental challenges, and life contexts. Strengths and limitations of the new manual are discussed, as are ideas about its clinical utility.

Core conflictual relationship theme--guided psychotherapy: Initial effectiveness study of a 16-session manualized approach in a sample of six patients

OBJECTIVE

This study examined the effectiveness of a manualized, 16-sessions, core conflictual relationship theme (CCRT)-based treatment.

DESIGN

Treatment effects were assessed for statistical and clinical significance in a pre- and post-therapy design.

METHODS

Six patients seeking help mostly for interpersonal difficulties received CCRT-based psychotherapy. The therapists were six supervised doctoral students. An average of four assessment sessions and one goal-setting session preceded 16 sessions of psychotherapy consisting mainly of interpretive work focused on one CCRT. Patients completed measures of general and treatment specific outcome indicators at the beginning and the end of therapy. Alliance measures were completed by patients after each session.

RESULTS

The alliance was strong and the treatment had high credibility. Parametric and non-parametric tests showed that patients significantly improved on the general measures of self-esteem, symptomatic distress, anxiety, and depression, as well as on the treatment specific measures of interpersonal functioning, use of immature defences, and CCRT-associated subjective discomfort, with large effect sizes.

CONCLUSIONS

These preliminary results suggest that this manualized, CCRT-based, treatment produces general and approach specific improvements. Replication is needed to ascertain its effectiveness with a larger sample size and within a controlled design.

Short-term psychodynamic psychotherapy versus treatment as usual for depressive and anxiety disorders: a randomized clinical trial of efficacy

This randomized clinical trial aimed to evaluate the clinical efficacy of short-term psychodynamic psychotherapy (STPP) in the treatment of patients suffering from anxiety or depressive disorders, as compared with a control case sample composed of patients undergoing treatment as usual (TAU). Sixty patients with depressive or anxiety disorders according to DSM IV-TR were randomly assigned in a 1:1 ratio to an intervention group (STPP) or control group for 12 months (T1). Primary outcome measures were the Symptom Checklist 90-Revised (SCL-90-R), the Inventory of Interpersonal Problems (IIP), and the Clinical Global Impression Improvement Scale. Intention to treat analysis revealed that patients who received STPP showed significantly more improvements in comparison with those who were in the TAU group on Clinical Global Impression Improvement Scale and IIP measures. This study offers evidence that STPP is an effective treatment for patients with anxiety or depressive disorders, and it could be more effective than TAU in improving interpersonal problems as measured by IIP.

A new scale for assessing the quality of randomized clinical trials of psychotherapy

CONTEXT

In 2004, the American Psychiatric Association's Committee on Research on Psychiatric Treatments appointed a subcommittee to investigate the status of empirical evidence with regard to psychodynamic psychotherapy.

OBJECTIVE

As a part of this effort, the committee developed a rating scale designed to assess the quality of randomized controlled trials (RCTs) of psychotherapy.

DATA SOURCES

A 25-item RCT of Psychotherapy Quality Rating Scale was generated by expert consensus. Interrater reliability, internal consistency, and validity testing were undertaken using 7 trained raters.

STUDY SELECTION

A PubMed search was conducted to locate all RCTs of psychotherapies identified by their authors as being "psychodynamic" or "psychoanalytic" in origin and implementation.

DATA EXTRACTION

A total of 69 RCTs were independently rated by 2 raters.

DATA SYNTHESIS

The scale was found to have good interrater reliability (total score intraclass correlation = 0.76), internal consistency (Cronbach alpha = .87), and external validity.

CONCLUSIONS

This scale establishes a new standard for the design and execution of psychotherapy RCTs and provides a systematic empirical method for evaluating the quality of published RCTs.

Treatment readiness, treatment engagement and behaviour change

BACKGROUND

Non-completion of treatment is a common occurrence in correctional contexts. Non-completion compromises service cost-efficiency, impacts adversely on staff and service user morale and may limit the effectiveness of therapy. Attention needs to be paid to enhancing offenders' readiness for treatment, and developing and maintaining their engagement.

ARGUMENT

In this paper, we state that research and practice in offender treatment readiness and engagement need to be driven in four major ways: (1) the construction of models of engagement that are theoretically based and empirically evidenced that can underpin assessments and treatments; (2) the development of psychometrically robust assessments of treatment readiness, motivation and engagement that can be used to select offenders for treatment or measure change over time; (3) the design, implementation and evaluation of pre-treatment preparation procedures that can promote treatment engagement and completion; and (4) the development of strategies that address barriers to engagement as an integral part of treatment.

CONCLUSIONS

This special issue contains contributions from leading researchers on the assessment of engagement, effects of engagement and non-engagement on outcomes, offenders' reasons for non-completion of treatment programmes, and the development of a measure of offenders' current concerns and life aspirations. These studies will improve research and practice in offender treatment readiness and engagement, and this could lead to better outcomes in terms of reduced re-offending.

Effectiveness of short-term psychodynamic group therapy in a public outpatient psychotherapy unit

BACKGROUND

Short-term psychodynamic group therapy in heterogeneous patient groups is common in the public Danish psychiatric system but is in need of evaluation.

AIM

To investigate improvement in 39-session psychodynamic group therapy using three criteria: 1) effect size (Cohen's d), 2) statistically reliable improvement, and 3) clinical significant change (CSC).

METHODS

Pre-post treatment naturalistic design based on 236 outpatients with diagnoses of mood (9.7%), neurotic (50.8%), and personality disorders (39.4%). Symptom change was evaluated on the SCL-90-R Global Severity Index (GSI) and subscales. Analyses were conducted on the total sample and after exclusion of 32 GSI pre-treatment no-cases.

RESULTS

The total sample GSI effect size was 0.74 indicating a moderate to large effect size (ranging from 0.67 in depressed to 0.74 in neurotic and personality disorder patients), which increased to 1.02 after exclusion of pre-treatment no-cases (ranging from 0.98 to 1.11 in depressed and personality disorder patients, respectively). However, in the GSI pre-treatment case sample, 43.1% were unchanged or deteriorated, 27% reliably improved and 29.9% obtained CSC status (ranging from 23.8% of the neurotic to 42.9% of the depressed patients).

CONCLUSION

Short-term psychodynamic group therapy is associated with medium to large or large effect sizes. However, even though many of the patients reliably improve, a substantial part of the patients are still, after therapy, within the pathological range compared with Danish norms.

CLINICAL IMPLICATIONS

Patients referred to public outpatient treatment settings may need alternative or longer treatment than 39 sessions of psychodynamic group therapy over 3 months.

Interpersonal, cognitive analytic and other integrative therapies versus other psychological therapies for depression

This is the protocol for a review and there is no abstract. The objectives are as follows: To examine the effectiveness and acceptability of all integrative therapies compared with all other psychological therapy approaches for acute depression.To examine the effectiveness and acceptability of different integrative therapy models (IPT, CAT, psychodynamic-interpersonal therapy, CBASP, counselling) compared with all other psychological therapy approaches for acute depression.To examine the effectiveness and acceptability of all integrative therapies compared with different psychological therapy approaches (psychodynamic, behavioural, humanistic, cognitive-behavioural, third wave CBT) for acute depression.

Psychodynamic therapies versus other psychological therapies for depression

This is the protocol for a review and there is no abstract. The objectives are as follows: To examine the effectiveness and acceptability of all psychodynamic therapy approaches compared with all other psychological therapy approaches for acute depression.To examine the effectiveness and acceptability of different psychodynamic therapy approaches (drive/structural, relational and integrative analytic models) compared with all other psychological therapy approaches for acute depression.To examine the effectiveness and acceptability of all psychodynamic therapy approaches compared with different psychological therapy approaches (behavioural, humanistic, integrative, cognitive-behavioural, 'third-wave' CBT) for acute depression.

Interpersonal, cognitive analytic and other integrative therapies versus treatment as usual for depression

This is the protocol for a review and there is no abstract. The objectives are as follows: To examine the effectiveness and acceptability of all integrative therapies compared with treatment as usual/waiting list/attention placebo control conditions for acute depression.To examine the effectiveness and acceptability of different integrative therapies (IPT, CAT, psychodynamic-interpersonal therapy, cognitive behavioural analysis system of psychotherapy and counselling) compared with treatment as usual/waiting list/attention placebo control conditions for acute depression.To examine the effectiveness and acceptability of all integrative therapies compared with different types of comparator (standard care, no treatment, waiting list, attention placebo) for acute depression.

Psychodynamic therapies versus treatment as usual for depression

This is the protocol for a review and there is no abstract. The objectives are as follows: To examine the effectiveness and acceptability of all psychodynamic therapies compared with treatment as usual/waiting list/attention placebo control conditions for acute depression.To examine the effectiveness and acceptability of different psychodynamic therapy models (drive/structural, relational and integrative analytic models) compared with treatment as usual/waiting list/attention placebo control conditions for acute depression.To examine the effectiveness and acceptability of all psychodynamic therapies compared with different types of comparator (standard care, no treatment, waiting list, attention placebo) for acute depression.

Evaluation of psychodynamic psychotherapy in a community mental health center

This study describes an evaluation of the effectiveness of psychodynamic psychotherapy provided in an outpatient community mental health clinic. The study used a single group pretest-posttest design involving 78 clients. Clinical outcomes included overall psychosocial functioning and quality of life, level of subjective distress, interpersonal functioning and role functioning, measured by the Outcome Questionnaire (Lambert, Hansen, Umpress, Lunnen Okilshi, & Burlingame, 2000). Clients showed statistically significant improvement from pretest (first sessions) to completion of treatment in overall functioning, and quality of life, level of subjective distress, interpersonal functioning and role functioning. Eighty-five percent of clients made statistically and clinically significant change. Calculation of effect sizes for each outcome found moderate to strong change effects ranging from d = .4 to .9. The study illustrates a method of intervention research that therapists and agencies can use to integrate practical evaluation methods into their clinical services in order to improve mental health service to clients, to demonstrate the effectiveness of interventions, and to provide data to support coverage for needed services for clients.

Non-completion of personality disorder treatments: a systematic review of correlates, consequences, and interventions

Non-completion of treatment is a major concern in the provision of therapies for people diagnosed with personality disorder, with adverse consequences for services, therapists, and other patients. Of even greater concern is that non-completion of treatment may limit the effectiveness of therapy for individuals. Our main aim in this study was to conduct a systematic review of the literature on psychosocial treatments for personality disorder to identify factors associated with treatment non-completion. Two subsidiary aims were to identify studies that reported the relative outcomes of treatment completion and non-completion, and to identify studies that evaluated psychosocial interventions specifically aimed at improving retention in treatment. This information is potentially useful in informing selection criteria and directing efforts towards improving treatment engagement. Twenty-five empirical studies of factors predicting treatment non-completion were identified. The median non-completion rate was 37%. A range of patient characteristics, need factors, and environment factors were identified as associated with non-completion. However, the studies could not be considered homogeneous group for meta-analysis. Four studies investigated the effects of treatment non-completion, showing an association with adverse outcomes. Only two studies of interventions specifically aimed at reducing non-completion were identified. Implications for clinical practice and research are discussed.

Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication

BACKGROUND

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. This article, one of five in the series, reviews new studies of psychotherapy in the acute and maintenance phase of MDD, including computer-based and telephone-delivered psychotherapy.

METHODS

The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. Evidence-based responses are based on updated systematic reviews of the literature and recommendations are graded according to the Level of Evidence, using pre-defined criteria. Lines of Treatment are identified based on criteria that included evidence and expert clinical support.

RESULTS

Cognitive-Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) continue to have the most evidence for efficacy, both in acute and maintenance phases of MDD, and have been studied in combination with antidepressants. CBT is well studied in conjunction with computer-delivered methods and bibliotherapy. Behavioural Activation and Cognitive-Behavioural Analysis System of Psychotherapy have significant evidence, but need replication. Newer psychotherapies including Acceptance and Commitment Therapy, Motivational Interviewing, and Mindfulness-Based Cognitive Therapy do not yet have significant evidence as acute treatments; nor does psychodynamic therapy.

LIMITATIONS

Although many forms of psychotherapy have been studied, relatively few types have been evaluated for MDD in randomized controlled trials. Evidence about the combination of different types of psychotherapy and antidepressant medication is also limited despite widespread use of these therapies concomitantly.

CONCLUSIONS

CBT and IPT are the only first-line treatment recommendations for acute MDD and remain highly recommended for maintenance. Both computer-based and telephone-delivered psychotherapy--primarily studied with CBT and IPT--are useful second-line recommendations. Where feasible, combined antidepressant and CBT or IPT are recommended as first-line treatments for acute MDD.

Direct diagnosis and management of emotional factors in chronic headache patients

Somatization, anxiety, depression and personality disorders are common features of many patients with chronic headaches. Intensive short-term dynamic psychotherapy (ISTDP) is a brief therapy method developed specifically to treat patients with this cluster of somatic problems, symptoms and maladaptive behaviours through focusing on how the patient handles emotional experiences. It also contains a direct method of assessing the somatic discharge pathways of both emotions and anxiety, thus allowing direct observation of somatization in the case of many chronic headache sufferers. In this review, we summarize the extant literature on emotional factors in headache, review the evidence for short-term dynamic therapies in somatic problems and describe the assessment and treatment method of ISTDP we use routinely with chronic headache sufferers.