Evidence Base for Psychodynamic Psychotherapy

Special Article

~ Psychotter Psychosom 200978265-274 ReceiledFebruJry 19 2008 AccIpted Iffi reVIsOIl JIII)Iamp 2008DOl 1011591000228247 PublHhed oollne lulln 2009

Short-Term Psychodynamic Psychotherapy for Somatic Disorders Systematic Review and Meta-Analysis of Clinical Trials

Allan Abbassa Stephen Kiselyh-d Kurt Kroenkee

Department of Psychiatry Centre for Emotions and tiealth and Departments of Community Health and Epidemiology and t Psychiatry D~housle University Halifax NS Canadai dSchooi of MediCine Griffith University Meadowbrook Old Autraliae Regenstrief Institute Indiana University School of Medicine Indianapolis Indbull USA

KeyWords Psychotherapy shorNerm Somatoform Psychotherapy psychodynamicmiddot Psychotherapy psychosomatk bull Psychophysiologic disorders

Abstract Background Somatic symptom disorders are common disshyabling and costyo Individually provided shorHerm psyshychodynamic psychotherapies (STPP) have shown promising results However the effectiveness ofSTP for somatic sympshytom disorders has not been reviewed Methods We undershytook a systematic review of randomized controlled trials and controlled before and after studies The outcomes included psychological symptoms physical symptoms social-occushypational function healthcare utilization and treatment conshytinuation Results A total of 23 studies met the inclusion crishyteria and covered a broad range of somatic disorders Thirteen were RCTs and 10 were case series with pre-post outcome assessment Of the included studies 21123 (913) 11112 (916) 16119 (762) and 79 (778) reported Signifishycant or possible effects on physical symptoms psychologishycal symptoms social-occupational function and health care utilization respectively Meta-analysis was possible for 14 studies and revealed significant effects on physical symp toms psychiatric symptoms and social adjustment which were maintained in long-term follow-up Random-effect modeling attenuated some of these relationships There was

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a 54 greater treatment retention in the STPP group versus controls Conclusion STPP may be effective for a range of medical and physical conditions underscoring the roleof pashytients emotional adjustment in overall health Future reshysearch should include high-quality randomized and clinical effectiveness studies with attention to healthcare use and costs Copyright e 2009 S Karger AG 8a1el

Introduction

Half of all outpatient medical visits are related to soshymatic complaints ofwhich at least olle third to one halfare medically unexplained [11 Many are individual physical symptoms such as pain (eg low back joint chest abdomshyinal headache) and nonpain (eg fatigue dizziness palpishytations) complaints Others consist ofa cluster of somatic symptoms for which the etiology is poorly understood such as irritable bowcl syndrome fihromyalgia chronic fatigue syndrome temporomandibular disorder and inmiddot terstitial cystitis These functional somatic syndromes ofshytcn overlap and are similar in terms of psychiatric comorshybidity functional impairment and family history [2-4J

Distressing somatic symptoms are also increased 2- to 3-fold in patients with depressive and anxiety disorders 156) More recently it has also been shown that diseaseshyspecific somatic symptoms in patients with a variety of

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_ J-IIltenlive Short-term DYnamic Psyehotbenpy for DSM IV PmouJity Diso~en

A Randomized ControDed Trial MM-J IrFlyengt d J (til 1 Abstract tw~frWJ~ Thi8 study eya1uated the efficaCy and long-term effectiveness of Intensive ShorHerm ~c

Psychotherapy (ISTDP) in the treatment o~patients with DSM IV personalitYdisorders (PD)

Twenty-seven patients with PD were ~mized to treatment with ISTDP or a minjmal-contact

de1ayed-llea1ment control condition ISIDP treated patients improved significantly more than J

controls on all primary outcome indices reaching the nmmal ranges on both the Brief Symptom- ol

Inventory (151 to 051 pltOOI) and ~nventory of Interpersonal ~blems (156 to O67PltOOI)----

When control patients were wated they experienced benefits similar to the initial1reatment

group In long-term fonow-up the whole grouP maintained their gains tUlLLhad an 833

reduction ofpersonality disorder diagnoses Treatment co~ were tluice offset by reductions in

medication anddisability middotp8ymeirts This preliminary study ofISIDP suggeSts it is efticaciOWI

and CltSt-effective in the ~t afPD Limitations ofthis study and suggestions (or futuremiddot

research are disCussed

Key Words Psychotherapy short-tenn personality disorder psychodynamic

DrPusaw AND ANJaItrrVf49-fn (2OOd)

BriefReport

INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY OF TREATMENT-RESISTANT DEPRESSION

A PILOT STUDY

AlIm Anthony Ahbass MD FRCPC ow

nu piltIt ~~ ti ~ if~ SIHwt- lJytutImk ~ (ISTDP) ~~t1f1 (lRD) 7M~ DiIh 7llDtHnr~lI_ tiflS7DP ~MtntlJNltimt1IIIIl hUttrjwAIOMl1llMlltllW IWn ~ IWIY 4 ~ lit --iaIRloa IIIIIIm foImP-tIp MMltlllilm ~ a4 IraquospitIIl tOJtI INn traquoItIfJIIIIW ~ IItIIr~ Iffr-tf116qf 1IIlbull w tIM fIWINIl ~ with IJUt pg 087 10 33 Gtmu rlJnY ~1Iud _fOImP-tIP ~~ teIV __ ~ eon

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middotINTRODUCTION T reatment-resistant depression (IRD) is a common underresearched clinical problem that exacts a large burden on patients and on the health care systclll Amiable evidence tI1J8BeSt5 thAt up to 50-60 of pati~ts do not respond Idequately to initial antideshyprc8SIDt triaIs [Fava 2003] Despite this thctc is bull noted absence of clbUcal tLia1s to support specific pbarmacotbenpewie augmentations [NelSon 2003] or psychotherapies LJhase et aLt 2001] in this cballenging patient catest7 Thus clinicians arc left widiout evidence OD which to base clinical decisions

Comorbid personaliq dDordcn and problema manashyging emotions have been touted as explsmatioDII for poor treatment response in some patients with depresshyaion Patients with personality disorders have defensive behavi018 that can intcm1pt the treatment relationship [Tbaae 2002] Problems identifying emotions aleshyithymia ft8 usociated with the 5enti of residual depltllldve symptoms in one recent Ogrodniczuk et al 2004 Gilbert et aI [2004] d f t over 80 of I sample of padenu with depJ8Slion directed anger tt themselves Theoretically any of these psychological problems can counter the efFecti of clinical mauageshymcnt if they are unattended

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DtmnIDo [1987] developed iDteDsive shott-term dyDamic psyclaothcrapy (ISTDP) to trDat patientlJ with depression and persomIity disordcn throush an emotion-focused process This treatment helps thecto overcome problems in ~ comp1ez

a ptQCeSS identi6ed as important m diverse research [Gilbert CIt al 2004 Ogrodniczulr CIt ai 2004] In bull randomized controlIed trial ISTDP produced wperior IUltidepressant effectJ to at more cognitive form of psychotherapy In symptomatic

AuooI ProfeuOr and DIreGIor of IduoIIkIn OtpInment of P8ychIIdryt Darhoueht UnMnilV HaIftaIc Nova 8cotIa canada ContraAIt grant eponeor Dettousfe Unlvelllty Depar1rnent of pll)Chlatry

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ReceiIed for pubICatIon 30 August 2006 RavIaad 13 DGceIIIbar 20M Accepted 11 Fabrualy 2008

DOl 1o10021da202QS PUbIIahed online 14 July 2006 In WIley Inler8CIence (www IntereclenceVtteycom)

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Short-term psychodynanc psychotherapies for common mental disorders (21(08106 S

Abstract

BackgroUDd Owl the past 40 years short-term psychodynamic psychotherapies (STPP) for a broad range of pSychological and somatic disorders have been developed and studied Four published meta~

analyses ofSTPP using difterent methods and satDplcs have fuund conftictin8 results

Objectives This review evaluated the cfficacyofSTPP relative to minimal treatment and IlOn-treatment V controh for adults with common mental disorders

Search stra~ We searched CCDANCfR-Studies and CCDANClRmiddotReferences on 25412005 CENTRAL MEDLlNE CINAHL EMBASE PsycINFO DARE and Biological Abstracts were also searched We contacted trialIists and checked references from papers retrieved

Selection criteria t

All randomised controlled trials (RCf)ofadults with cornmm mental disorders in which a ln15f V psychodynamic therapy lasting 1css tbau 40 hours in total and provided in individual ibrqt were

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Data colledlon amp analysis Three reviewers working in pairs evaluated studies StiJdies were selected only ifpairB ofrevitwers agreed they tmt inclusion criteria A third reviewer W1lS consalted if two reviewers could not reach consensus Data wen collected and entered into ReviInv Manager Study quality was assessed and scored by pairs ofraters Publication bias was asSessed using a funnel plot Sensitivity analyses were also conducted

Reviewers conclusions STPP shows promise with modest to moderate often sustained gains for a variety ofpamptients However given the limited data and heterogeneity between studies these findings shoukl be interpreted with caution Furtherinore variabiiY in tmatrmnt deHyerY and treatment ltffility gy limit the reliability ofestimates ofeffect for STPP Larger studies ofhigher quality and with ~cifiC diilSnoses are waniiited

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Short-term psychodynamic psychotherapiesfor common mental disorders (2108tI6 4

Synopsis Short~termps)dlodynamic psychotherapies fbr common mental disorders

Short-termpsydJodynBtnic psychotherapies have ~ subjected to randomised controlled tliak for a range ofcommon mental disorders including anxiety disorders depression stress-related ~ conditions certain behaviour disorders and interpersonal or personality problems mixed with ByllJptom disorders Previous mda~analyses have yielded conflicting results This review included an ReIs ofSTPP fbr common mental disorders and fbund modest treatment beoefits that were generally maintained in medium and long tCDllfbDowup However variability in study design means that our eonclusioDs are tentative and need coofirmation with further research

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-Psychotherapy Research 1()(2) 215-234 2000 02000 Soddy Cor Psychotherapy Research

SHORTmiddot AND WNG-TERM EFFECTS OF MEDICATION AND PSYCB011lERAPY IN TIm BRIEF TREATMENTmiddot j

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0 DEPRESSION FURmER ANALYSES OF DATA IFROM THE NIMH TDCBP

Sidney J Blatt Yale University I David C zuroff I McGiU Untversity Colin M Bondi Charles A Sanislow m

Yale University

on -shyences emerJlea at tile lsmotWflODOWmiddotUD in

Of treatment on their life adjustment Patients in 1FT ~ greater

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nu Treatment of Depression Collaborative Research Program (TOCRP) sponsored by the National Institute of Mental Health (NIMH) compared two forms of brief psJchotherapy for the treatment ofdepression-Cognitivewbehavioral therapy (CST) and Interpersonal therapy aPD-with Imipramine plus clinical management (IMlshy00 as a standard reference condition and with pill placebo plus clinical ~nageshyment (PLA-CM) as a double-b~ control (Elkin et aI 19$) Clinical management consisted of nonspecific supportive interactions lasting 20-30 minutes (Elkin Parloff Hadley amp AUtry 1985) In a carefully controlled three-by-four factorial design 239 outpatients with major depression were randOmly assigned to one of four treatments

Correspondence reprdlng tid article should be Addressed to Sidney I Blatt Room 612 2S Plllk Street New laven C1 06519 Telephone ~735-lO9O fllt Q3-785-7357i 8-maU SldnllYBtaneyllelaquoiu

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Evaluating Three Treatments for Borderline Personality Disorder A Multiwave Study

John FC1arkinPhO ObJective The authors examined three behaYfor therapy Wet( significantly assoshyyearlons outpatient treatments for barmiddot ciated with Improvement iii sutcldallty

Kenneth Nlevy PhD derllne personality disorder dialectfcal Onlytransferencefocused psychotherapybehavior therapy transference-focused and supportive- treatment were assodshy

psychotherapand a dynamicsupportiYe ated with implOVeflent in anger TransshyMark F Lenzenweger PhD treatment ference-fDcused psychotherapy and supshyponlll treatment were each associatedMethoch Ninety patients who ~ eliasshyC)tto F Kernberg MD with ImplOWIment In facets of Impulsivshynosed with borderline personality disorshyIty Only transferencemiddotfocused psychoshyder were randomly assi~ to transfershytherapy was slanHlcantly predictive ofencemiddotfocused psychotherapy dialectical change In Irritability and verbal and dibehavior therapy or supportive treatshyrect assaultment and nCeIYed medication when Indlshy

cated Prior to ~t and at +month Conduslons Patients with borderline intervals during a 1-year period blind ratmiddot personalltydisorder respond to $trueshyers assessed th~ domains of sulcldal_ be- tured treatments In an outpatient settlns havipr auresslon ImpulsIvity anxiety with change In multiple domains of outshydepresslon and sodal adjustment In ill come A structured dynamic treatment multiwave study design transference-focused psythothenpy _

ResuItsllndlvldual (pOWth-curve analV associated with change In multiple conmiddot sis revealed that patients n all three structs across six domains dlaledlcal beshytreatment croups showed significant pos- havior therapy and SUPPOrtive treatment

ftlve change In depressionarudety slobal were associated with fewer changes Fu functlonlnamp and social adjustment across ture reseanh 1$ needed to eumlne the 1 year of treatment Botti transference- speclflc mechanisms of change In these focused psychotherapy and dialecticalmiddot treatments beyond common structures

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Impulsivity dlminlabed nonaffectlve coQStJain~ nesashytive affectivity and emotional dysregulaUon ate core charmiddot acterlstlcs ofbordrllne personality disorder (I~) The prevalence ofborderline penoDSlity diaorder In the comshymunity cohort of the present study is approximately 13~ to l4~ (4 5) IbJa c1uon1c and debilitating syndrome 18 assodated wtthbJgb rates ofmed1cal and psychiatric utillshyzation of ~ (6 7) Psychopharmacology notwithshystanding psychotherapy represents the recommended prlmary tedmlque for treatinamp borderline personality dismiddot order (8) Dia1ectl~ behavior therapy (9) baa demon amptmted supedorlty over thlatmeDt-as-usual (10) and thershyapy by community experts (11)

Other therapeutic approaches sudlu psychodynamic treatments continue to be prominent in the treatment of borderline peltonaUtY disOrder II supported by the KiA Practice Guldellne (8) arid prior research (lZ) AProin1lmiddot log psydlodynamlc treatment approach 18 WI object relashytions approach caned transference-focused psycbothershyapy (U) Transference-focused psychotherapy Ie an

effective treatment using patients as their own comparishy80ns (14) and hu middotd~Qnstrated superiority over treatshymentusual (unpubllsheddata byCABinks etalavaiIshyable from the aUthors)

Anecessary and first step in mumtnating effectiw treatmiddot ments for borderline peIllOnaJity ~rcleris to showtbat a glven treatment iB associated with signtftcant improveshyment In the disOIder-improVemerit in relevant ~menmiddot rdons ofpathology beyond self-damaging behaviOrs Bmshyphtcal eVidence should show that candidate treatments such as dialectical behavior therapy and psychodynamic approaches are Iystematically related to change in a number ofS1bItantive domams of cHnical sigDificance A recent influential ~w reported that exi8ting therapies for borderline personality disorder remaln expenmental and more xeaI-world atucampa are necessary (15)

We examined patients who weretaken from tluI commushynity and reliably diagnosed with bordexllne personality diBorder PatlentB weIe randomlyasajgned to transferenceshyfocused psychotherapy dialectical behavior therapy or

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Am) Psychiatry 1646June 2007 ojppsychlatryOniineorx 1

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jPsychorumztly RetItlrUl Octoberl~ UD) 562-Si2 I~~-~

Reladve efficacy of psychotherapy and pharmacotherapy-in the ~~

treatment of depression A meta-analysis shy

s~KIA DB MAAT JACK DBKKBR ROBERT SCHOEVERS) amp FRANS DB JONGHB

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In the past 25 -ears a Dumber ofreviews and metashyanalyses comparing the etllcapy or paychotberapy and pbarmacotberapym depression have been conducted (eg Cuacalend~ Perry) amp Looper 2002 DeRubeis Gelfand Tang amp Simotla 1999 Dobson 1989 Gloaguen CottraU Cucherat amp B1ackbutil 1995l Ho~ Jarrett et aL 2005i HollOllt Shelton lie Loosen 1991 HoUoD ~ 4t ~ 2002 Jarrett 1995 Robinaon BermaD amp Neimeyer 1990 Royal Awnralim and New Zealand con of Psychiatriatl 1983 SteiJlbrued Muwel1 amp Howard 1983 WeinmlUl Jarrett amp R~ 1987 Wezlcz amp Cicchetti 1992) It has been argued that mmy of 1hCle reviews and metamiddot~ present methodological limitations They often do not provide imention-to-treat (lTI) analyses present effect sizes from which obviously no remission rates can be deduced include flawed studies (eg studies that did not UlH II1andard1zed diasoottic criteria) and present rcsponee rates instead of remission rates (Casacalmda et aI 2002) An even more important IirDitation may be the strikinc methodological and c1inica1 heteropneshyity of the 8tUdiea Included in most reviewI and metashyanalyses Clinical heterogeneity rden to differences in patient wnplea treAtrnent protocolamp and treatshylllent settirlp aaobull stUdies We mention t1tree examples In Cuacaleada et 818 meta-atl81yais (2002) tbtee trialamp reprd primary care patients

whereas the other three 1liaIa eontider ~ outpatients TeIItment duration vadc8 from 10 to 34 weeks Psydwtherapy conditions iJ1dude oognitivc therapy and interperJOnal ptJebothcrapy as well as problem-eolviug therapy and social work coUJlllftling In the meta-analysia of Gloaguen et aI (1998) Httiaga vari IWeD more iDdudiDg hotpital patientB outpadmt5 volunteers stwimtB ad~ and geriatric patients lhatment dmation vadea from 4 to 79 weeb Not amprisiDg1y1l tbe authon ftequent1y report that tb hypothesis of inta1ria1 homogeneity wu rejected The review of HoDon Jamm et al (2005) ~ priInary CIU geriatric and adult in- and outpatients 81fferini from dya1hymia or IQajor depmsive cUsorder (MDD) A11hough aome of the reViewcJI (eg Gioaguen et aI 1998) do address the iuue of beremgeneity most of the ~ and meta-analyses mentioned preriously do DOt indude atadstical maly8es aaeaaing the influshyence or the cIinical heterogtneity on the review outcome Clinical heteroaeneity 8DOD8 studieI inshycluded in reriewa or mem-aualyses JIlIIbs data pooling bazatdoua (aee CocImmI ~ HawJ book 422 CocJtane Collaboration 20(4) It cershytainly does not dow apecitic conclUlions regarding particular patienm groups or setIiD8B Hetetogerleity may provide a partial etplanatlon for the rather inCODlistmt condwlions reached by different reshyviews Many of them conclude that psycbotbetapy

Cormpondmce Jack Dekker ~ of BaeIreb Memrum Mmal Kealdl AmIteIdIm KlIpiOlC1lWlamp Ill POIIbuI 71_ Amsterdam I (liOA The NlldJerand

ISSN 100-3307 p1i11t~ 146amp-4381 0ftJiDe C 2006 Society for ~ ltIIIeIrdI DOl lO10801050UOO600T56402

Article

Therapist Affect Focus and Patient Outcomes in Psych()dynamic Psychotherapy A Meta-Analysis

Ktarc J Diener PhD ObJective The authors systematically therapist tidlltllltlon of patient emotiOnal

I examined the relationship between her experienceexpression and outcome

Mark J Hl1senroth PhD apist facI1ltatfon of patient emotional ex- when more than one outcome construct perienceexpresson and outcome In psy was included but not when either a slnxte chodynamic psychothera~ or an unclear outcome construct was oel WeInberger PhD Method Computerand manual searches used Th1re were no signmcant relationshywere conducted for relevant publications ships between methodological quality and 10 Independent samples of short- and the size of the effects although use term dynamic psychotherapy were In- of audio- or videotaping for supervision eluded In a meta--anaysls Data analysis detnOn$11ated at mode1jlte effect

Included calculation of an overall effect Conclullon These data Indicate thilt size of the relationship between therapist therapist fadlltatlon of patient affective affect focus and outcome statistical slgnlf- experiencelexpr1S5lon is associated with lcance and test for homoaenelty In add- patient Improvement OYer the course of lion moderator analyses were conducted psydlodynamic psyChotherapy Although to examine the potential impact of type of the size of this relationship was not signlfshyoutcome construct used and the method- icant related to methodoloslcal qual~ oIogkal quality of IndMdual studies raLllts sugest the Importance of cI~ Results The overall average weilhted ef- supervision 01 actual techniques through ftd size across all outcome types was Ita- the use of audio- or videota~ Additionshytlstfcally slgnmant (r=O30) and the ho- ally results hipllsht the Important of mage-neily statistic was nonslgnlflcant deffnlng outcome In it multidimensional Moderator analyses fndlcated a statlstl- way to properly assess theoretically tieshy

cally significant relationship betWeen vanteffects

Anwn~ of meta-analJHIII have demonstrated the owrall efficacy of peychodynamic therapy or short-teJm dymunicpsyclwtberapyacroI8 difleIent types ofdiaordere (1-2) and for specificpsychiatricdiaordere (3-4) However the rnechanIsmII ofactIon that IUCOUIlt for this effialcyreshymain to be determined and studies designed to clarIly them represent the natural nut step inresearch on shortshyterm dyJJamic paycho~ In this type of research inshyvesttga~ seek more speciflc answers to tile ~erennial qUestion ofwhat worb In psychotberaPlt Rather than10shycWdng on questions of main effectt (eg Does oognitlve behavior therapy work better than a control condition for the treatment of major depre881on-) researchers can identity potentially more cliDically meantnsful ~ by

-Isolating the correlates of 8 particular set of interventions (6) By examlnlngthe potentiallmpactofparticular seta of IntelVentions ~ben can help dlniciaD8 work more effecdvely and f1exiblywitb their patientamp Ibfa enables c1ishynIdaJis to dlDose from a variety of emplltca1ly supported lntervendon strategies u approprlllb) undel the dhUcel ~rathertbanbetngforced to work w1tbln the

(Alii JPsyt6it1t172007 164f36JU1J

limitations of a single manuaHzed approach for a patient who has a spedamp disorder (5)

An affective treatment focus repreaents a releYant mechanism ofaction for short-term dynamic psychothershyapy as reaeateh indicates that contemporary psychody- D8JDic thempie$ place greater emphae18 on encouraging experience and expression offeeUngs compared with cog nitive bebav10rtherapies (6-8)Ablon andJones (6) for exshyample asked expert psychodynamic and cognitiw behavshyior therapists to use a Q-sort-derived questionnaire to describe an Ideal paychotherapy oftileD xeapective orienshytations Results indicated that the ideal psychodynamic therapy In contrast to cognttiye behavior therapy conshytained agte6ter focus on patient sIIect Jones and Pulos (7) uamlned proceIamp ratinga of psychodynamic and cognishytive behaVior therapy sessions and demonsttated that dyshynamic therapy contained greater affective emphasis Blagye and HOsenroth (8) In a review of the comparative pqchotberapy process llterature identif1edseftD techshyniques Of proCe11e8 that dlstfnguish psycbodynmmcmiddotlnshyterperaonal therapy from cognitive behavIor therapy

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Display Settings Abstract ~NIPam1 CUo PSYchol Rev 2010 Feb30(1)25-36

The efficacy of short-term psychodynamic psychotherapy for depression a meta-analysis Odesse J GUiioers p de Maat se Abbass M de JQnghe E Dekker JJ

VU University Amsterdam Faculty of Psychology and Education Department of Clinical Psychology Van dar Boechorststraat 11081 BT Amsterdam The Netherlands edriessenpsyvunl

Abstract OBJECTIVES It remains largely unclear firstly whether short-term psychodynamic psychotherapy (STPP) is an effective treatment for depression and secondly which study participant or intervention characteristics may moderate treatment effects The purpose of this study is to assess the efficacy of STPP for depression and to identify treatment moderators

RESULTS After a thorough literature search 23 studies totaling 1365 subjects were included STPP was found to be significantly more effective than control conditions at post-treatment (d=O69) STPP pre-treatment to post-treatment changes in depression level were large (d=134) and these changes were maintained until 1-year follow-up Compared to other psychotherapieS a small but significant effect size (d=-O30) was found indicating the superiority of other treatments immediately post treatment but no significant differences were found at 3-month (d=-O05) and 12-month (d=-O29) follow-up Studies employing STPP in groups (d=O83) found significantly lower pre-treatment to postshytreatment effect sizes than stUdies using an individual format (d=148) Supportive and expressive STPP modes were found to be equally efficacious (d=136 and d=13Q respectively)

CONCLUSION We found clear indications that STPP is effective in the treatment of depression in adults Although more high-quality RCTs are necessary to assess the efficacy of the STPP variants the current findings add to the evidence-base of STPP for depression

PMIO 19766369 [PubMed - indexed for MEDlINEJ

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Resent-From stdpflstmail-listcom From Tony Rousmaniere PsyO lttrousmaniereyahoocOOlgt

Subject [EDT-USTJ STDP research Date October 6 2011 65325 PM EDT

To stdpmiddotliststdporg

New STOP article in the journals

Exploring corrective experiences in a successful case of shortmiddottenn dynamic psychotherapy Friedlander Myma L Sutherland Olga Sandler Steven Kortz Laura Bemardi Shaina Lee Hsin-Hua Drozd Agata Psychotherapy Oct 3 2011 No Pagination Specified dol 101037a0023447

Abstract The concept of corrective emotional experience originally formulated by psychoanalysts Alexander and French (1946) has been redefined by contemporary researchers to be theoretically nonspacffic that is as coming to understand or experience an evant or relationship in a different or unexpected way (Castonguay ampHill 2011) Using postsassion questionnaires videotapes and posttermlnation interviews we explored whether (and how) acorrective experience occurred In a successful case of short-tenn dynamic psychotherapy (STOP Oavantoo 1980) A 35-year-old woman suffering severe panic attacks was sean for 31 sessions by an experienced STOP therapist The questionnaires and interviews focused on (a) perceived intrapsychic and interpersonal changes and (b) how these changes came about At termination the client reported complete symptom relief greater self-acceptance improved relationships and more emotional flexibility Her corrective experience was evident in the qualitative themes which showed that she came to understand and affectively experience her relationships with both parents differently Moreover the themes reftected both STOP-specific (egbull confrontation 01 defenses) and nonspecific (eg rapport acceptance) mechanisms of change Conversation analysis (Sacks 1995) of what the client described as the gentle shove of questions that make me see what I have been trying to ignore since childhood showed on a microlingulstic level how she overcame resistance to strong emotional experience and expression (PsycINFO Database Record (c) 2011 APA all rights reserved)

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~~fy~ia1I 2010 Sep 15 [Epub ahead of print]

A Quality-Based Review ofRandomized Controlled Trials of Psychodynamic Psychotherapy Gerber N Kocsis JH Milrod Bl Roose SP Barber JP Thase ME Perkins P leon AC

From Columbia College of Physicians and Surgeons and the New York State Psychiatric Institute New York Weill Comell Medical College New York Department of Psychiatry University of Pennsylvania and VA Medical Center Philadelphia Department of Psychiatry University of Pittsburgh Pittsburgh

Abstract Objective The Ad Hoc Subcommittee for Evaluation of the Evidence Base for Psychodynamic Psychotherapy of the APA Committee on Research on Psychiatric Treatments developed the Randomized Controlled Trial Psychotherapy Quality Rating Scale (RCT-PQRS) The authors report results from application of the RCT-PQRS 1094 randomized controlled trials of psychodynamic psychotherapy published between 1974 and May 2010 Method Five psychotherapy researchers from a range of therapeutic orientations rated a Single published paper trom each study Results The RCT-PQRS had good inter-rater reliability and internal consistency The mean total quality score was 251 (SD=88) More recent studies had higher total Quality scores Sixty-three of 103 comparisons between psychodynamic psychotherapy and a nondynamic comparator were of adequate quality Of 39 comparisons of a psychodynamic treatment and an active comparator six showed dynamic treatment to be superior five showed dynamiC treatment to be inferior and 28 showed no difference (few of which were powered for equivalence) Of 24 adequate comparisons of psychodynamic psychotherapy with an inactive comparator 18 found dynamic treatment to be superior Conclusions Existing randomized controlled trials of psychodynamic psychotherapy are promising but mostly show superiority of psychodynamic psychotherapy to an Inactive comparator This would be sufficient to make psychodynamic psychotherapy an empirically validated treatment (per American Psychological Association Division 12 standards) only if further randomized controlled trials of adequate quality and sample size replicated findings of existing positive trials for specific disorders We do not yet know what will emerge when other psychotherapies are subjected to this form of quality-based review

PMID 20843868 (PubMed bull as supplied by publisher]

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__ laquomJt May 2006 16(3) 293-305 ra usPzvc1w~

Eftects of trabltng in short-term psychodynamic psychotherapy1 Changes in graduate clinician techJdque

1 1 2MARK J HILSBNROTH raquoJARED A DEFIFB MATrHBWD BIAGYS J amp STBVBN J ACKERMAN

171u Dmw ~ qf~d~~ AdIIph UniwrriJy amp 2n Bril Bri1IMm 11111i1uu durtttn Rill 0IratIr and HMfJafd MfIiir4l ampMol

(RNJrtiwd if ~1003 PIIIfrIIIIIO ~ zotH ~ JO ~ 20tH)

AhIcnci TId study investIaatel the drccts ofaraduatccliniclan traintq insbon-term ~ pIIYChothcrapy (STPP Book 1998 IuboralcJ 1984 Strupp amp BiDda 1984 Wadltel 1993) an the acipliaidoa of ~ within aad across two traItDng CUes SeuioDs 3 and 9 fiom the amprat and ICCODd trefltment cues of l graduate cliDidatui ~~ tratnIaI in STPP ftnI eurninrltl fOr the hqUCllUly of paychaclJDamic-iruerpenonal (PI) tberapeuric tcdmiquce Reauka demoaItuted that amptn1dlIrCd 1niDIaa in STPP led 10 bull aJanificandy increaaed UIIe ofPI thcrapeudc ~ both within and K1OII cua 1be IQlthom alao examined the tieqwmcy ofcopillve--bcbmom (CB) ~ tcdmiqneI med by the fP8CIute CHniciItl8 No cbaDpi In the number of GB ~ were obaemd over the 8IIDC Bet ofaeuions PracdaIl implbtioas for the UIIe ofIIInICtIJred clirdcal tadnlug and Jasuea perdnmt to lIUPCIisionin gradua1e education ate nriewrd ~ the impaCt ofstrLlCtUrCd tniniq on azacluaul clinicians abIJtty to lbrm poIdtive ~ relatioDllhlpe with dWt

patieIWi is tao dIIcuaaed

The ~tudJ of atructUted approaebet to training and the acquisition ofdhrlcal skiDa baa become an area of increUed Interest ovu thelaar decade A number of

authors have addressed thia iatuc~ and there baa been the apressed desire for reaeardl on the direct reladonahip between training and the IUbsequeot icqviaition of specific clinical IldI1a related to th1a uaJning (Bcmard amp Goo~ 2004 BcIltler amp Kendan 1995 Binder 1999 Holloway Neafeldt 199~ Miller amp Binder 2002 Patton amp Kivligban 1997 Stein amp Lambert 1995 Stnlpp Butler amp Rosser 1988 Watkins 1997) Such evideDce of a relationship between the tpedficity oftraining and skilllevcl achieved will allow for an evaluation of the premUe that akill acquiaition in the provision of paycholosica1 therapies like skill in performiDg any campIer behavior derives more Jioom the uae of 1arJetCd coals specific feedback aDd guided practice than ampom limple ezposure and ~ supershyvision (Beutler Be Kendall 1995 p 180) However there has been limited empirical research concerning the etfecta of structured cllnicaJ training on the acquiWon of therapeutic techniques

Some notable ~ reprc1lng training in short-term paychodynamic paycbotherapy (STPP)

have 6een the work of Henry StrUpp Buder Schacht and Binder (1993) MuItorJ Kivigban and Gold (1996) at weD as Criu-Cbriatoph et aL (1998) These ItUdica baveeraminod the impact of manuaHzed trII1ninamp on ~ acquiJition of psychodyshyJWIlic thcrapeutlc akills and pa)Chotherapy procese The first of these studies (Henry Strupp et at 1993) found that after manualizcd traJnJna in timeshylimited dycwnic psychotherapy (TLDP one form of STPp) therapists were more active in exploring inshysersaioJ1 affect the therapeutic reIatioJllhip uaing opcm-endc(f questions and dcm~middotweabt adhenmce ~ themiddot treatment model conaittent with the manualized protocol being tauaht This inshycreaaed UK of nDP tedJpiquea ~ for both global dynamic and specific nDP mtervcntiona in the comparlacm of 1CBIi0000middotfiom two C3ampeamp before nDP uaiDinJ with two CII8e8 after trainina was completed In regard to the aapecrs of aupervbdon that were moat effective in the development of theBe tecbnical ~ Ficnry Schacht Strupp Butler and Binder (1993) found (with reprd to HenryJ Strupp et al 1993) dear ~ in the dfecIJ that focused supervision qm hae OD trainees undelshytakiDg strUCtUreC traiuing in TIDP Specifically

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ORlGlNAL~

The therapeutic relationship ~e8rch and tlleory

An introduCdOD to the SpeCial Issue

ADAM O HORVA1H

Simon Fwa8r ~~ CaMlltJ

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Ibc pJace of the tbezapeu1ic ftliariomlbiP in p8JCb0tbcrapy reseanh is ~ in ldsrorical ~ 1bDowed by bull briefreview ofthe major xl1llCllldl tlumea wkbJn this topic ada11I9iewofwbatia cowred in tbB Jpeeial secdon Socu oftbe sttenampt1u ofthll body oftJOrJr 811 WtIll as the ~ laquoball ariaiDs014 of the re-em~ofThe~ ptIDshy~ COMCPt captUIfna ~ nlational dyDamiQ of tbcrapyl arc dfKuIacdbullJtrcom~~ ibr ~middotthe ~-concrptual diaIope on what ~ the ~~ in cWrerem therapeutia oomat aDd diSnnt pbues of~ rue protided

Kowordss ~-~I) tJIIitmr ~ proui ~

Research 011 tbe relIldcmddp ~ thempy of therapeutic procc88 In a briefpaper Preud l8id themiddot tbmdatiQn ofwhat wgUzct be later elaborated 81

The dcdkatiOll of a apcdal iasue of~ tl1e concept of the alliance by Uqting the ~ ~ 0 lbetopic of the therapeutic rcJationShip

of the development of the [paticlltl bullbull Ittichfhtamp]rDubasignificant milepostbJ ~ bistoryofempirica1 himad to dlC dodOi~ andmiddot1inIc [hJm] with researeh on ~processmiddot The editon~ images of people by whom heWSI aceustomed to ~ deciaion to devote dda tnrteI1ded ibrmat to the topic 11 be ttea~ witI1 affccdom~ (Fren~ -1913) While I

mbolic ofa powinarecoanitioD of1he maturity and Preuda Jnsiglmt hIVe done much to enable (lJe fvalue ofthisbody ofwotI Jhiis pseaerlts aDimportant IIJItema1ic ~tion of mentsl proceaaes by theoppoqtDlityto Umwcaacanew pziendionof~c

bqpm1ina of ~ nineteemh centary it became tiDquiriea hlgbliabtiDg tome of the iaaue dlaJlen8iD8 appareot that if pI)choth~Pf WIll u) become il those ofuawho dcrdre to moVe the empirical iDYeatipshy scimtificaU based ~onraquoJ it needed a tbeoty lion ofthe tcJadoDal aspect ofplJCbotberapyforward~ that could generate robust ~tab1e hypotMsa IAI a fiameworlc ibr dda oveniew of the current The~e of cievdopinglIll eD1piricaJlJ tieta- Irelationahip research ageoda ~bistorlca1 CODtrst of b1e model ofhuman change V first taken up by the )

dda body ofrcaearch wDl bebriefly ~ followed bChaviorilDl (Skbmer 1974) The advamagea aod by a aummary of the empirica1 investiptions of thC opportuniriea oftcted by a model buedon obJerVashyaUiance in psychothenpy in the past three decacJe ble behaviors were signifiCant However ~1dingandmoreapeclfically iDtbiaapeclal~Fmally the u phcnOmcDa beyond that which could be observed cha1lcmga lying ahead 8ft discuaIed and verifiedmiddot It the tbzie meant that not only the

IIlatodca1 CODtext therapy relationshiP but cogniUve procesaes as wcJll were moved beyond the domain of euqrirical re-

The relationibip betwecll dunpist and client bas seardJ By the midQle of the twet1tiet1i cenNIY hiItorlcaUy ~ a promiDent ~le inth~ theories techno1oaica1 hwdvatiOllB made it pOlllible and l ~ MIlD O ~ CouDIeIHnamp PAycholoay PoamprIm SlIDoD Prucr ~ 88Ba u~ Way ~ DC I ~A 186 B-mIik ~ca

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piactical to produce live recordings of therapy scsaions opening the way to empirically reliahlc exploration of the PfOOe88 of psychotherapy Tbiashynew teclmology and Rogers interest in the relation- ~ broadened the horiZon of psychotherapy ~ search The therapeutic re1ationlhip became once

Qgl$ the ~of attention of some researcbcm While much Of me post-war ~ fbcuSed 011

firidirtg specific ingtedients responsible for positive therapeutic gains advances -in ~ eynthesis (LnborskJ Singer amp Luborsky 1975 Smith amp Glass 1(77) yielded compelling empirical evidence that an -element or elemetm commOn to the broad aoss ~ ottherapeutic practicea ate responsible for Jarse portion of beaHnr effects Ibis finding renewed inteft8t in role of the telatiomhip bciween therapist and client An esamtial component in the subsequent momentum behind rcseateh on the ~tic relationabip was the theorerlca1 work of Luborsty (1976) aDd Bordin (1976 1980 1994) Their elabOration aDd ~aion ofGreeDaon (1965) shyand Zetze1s (1956) work on the payehodynamic

~ of the therapeutic and working a1Uarue resulted in a pan-theoretical fomwlatiOli of the

relational coDlponent of therapy Between 1975 and 1986 there were a number of

measures developed to qiJUuity the quality ot the alHance in helping Rlationahips While the instru- ment development and ~t projects opened the way to investigate this concept there fm1ined a Rignificint reUdual ambiluity abOut the theoreticall conceptual Ctelinition of the a1Uance (Hentachel

2004 Horvath at Greenberg 1989 Horvath at Luborsky 1993)~

Reeoarch _0IIlP11ahmeDt8

It ill uaefoI to reflect on the amprOwina volume of raearch 011 the alliance u represenq two eomoshywhat chronologically and topicanY overtappinamp phases initially much of the investipton energy focused on exploring the relation between the alliance and therapy outcome acrosa various helping C01lteXtR The ftrlety of COnteID explored in tbIa phase included different typcB of rreaunentadivcrsc populadoDBand diaplostic catcgoriea gender efshyfects 88 well 88 some therapist acton such aslevels oftherapiat ttainhic and experience Another area of inteR8t from the beginninr was the relation between OutltOllle and alliance aaseued from different pershy~ (ie client therapist and observer) as well as the mapiliude of the alllmceIoutComc relation at diffetent pbaaes of therapy (see Horvath at Dedi 2002 Horvath amp SJIllbndl 1991 Manin Ganke) amp Davia) 1(00) At a riD of lIDoring complexity a reasonable summary is dlat the r~ati01l8hJp8 reshy

ported acrose ~ have been quite coaaistem the aJliance-outcome corre1atiOD is moderate but Bigrdfi cant (rmaea 13om 22 to 29) clicnts Uleninenra tend to be more predictive ofoutcOme than are other sources early allianCe fa as gnod or better prcdictor of outcome than asaessment8 takeb later and the

alliance as measured appura to be related but not identical to paraDe1 therapeutic gaiba

Somewhat overlapping in tlrm8 ofchronology but distinct in thematic intere8ta is the aecoDd phase of altiance research these investiptiODB middotplace leu cmphasisOn the ~aJli~ ~on 88 such and foc1s more on the role deve1opmen~ aDd management of the alliance in tberapy ioeIt For eump1ercsearchcrs have aammed SoMints (1980)

proposJtions about f1uctuatioiu (team and repairsin the aUiaDee IS core opportunities for therapeu1ii pin (e Sattan amp Muran 2000) difrerenca across clients in terms of ~ kind of relation they desire with their therapist (e BatdJdor 1988) euinshymadon of thcrapillt qualbiea and ~ors that Ire

asaocIated with client percepdQ1J8 of ampood alliance (e~ Henry amp Stuppl~ HDsemoths Ackerman

Clemence S~e amp Handler 2002)

ChaJleraps ahead

Given the ricbnea and accomplishment oftlUa line of bull research what arc the chaJJenpa we mJgbt anticishypate Pintly we need more theoretical debate abOUt gt

the ~ofthe~ The Idariftlybrief period between the initial tbeorcdcal~tuaI forDlluation and the ~ of m~ p~ that inpractkedefined the ~ for

researcli that foDoftd Hbly fQredosedthe opportU- nityto examine the implications and p08ampiblc fimita tiona of itxe concept fiistpresented by Lubonky gt

(1-976) and Bordin (1979) MOLeORI noving the concePt from itB orlginal psycbodynamic conttxr and framirJc it saa pan-thcoretkal variable isolated the niance from a broad theoretical bmework of therapy and change Bordin (1994) began the wodt of exploring how aspects of the aDienee miaht artic$te with other aspecb of thempy but these Brat stepa wete not taken up by otbm and a nUmber of importaut unresolved issues remain Mdit DbshyviouslYJ the question wbether the allianCe is inttselh curative CODlponCllt of therapy or whether the relationship creates the interpersoJlll1 conteXt necet-

sary for other tberapcutic e1ementuto come to bear on the client problema In addition the dynamic IMllution of the thirapeutitrelatiombip over time end perhaps ira UDique unfblding wtthln pardeular diapottic coDtext needa t() be inVeltipted

Second the field needs to struggle with the question ofhow merapism am be trained to develQP

~ mMllrh Qftrl rIMorJ 5

better a1lianies with their cliental IDitial etIom to be due to such bomopneity myth A more train therapiats teBUlted in paradoxical effect mmy detailed and diacrimmaring examination of diema and col~ (1993) ~ the results of what cxperieoee of the tbtrapeutic rel8tionahip in latcr apped to be an excelienr iraiDha Program but it phuu of tbi wort ~ within mediuni and failed to improve the quality ofatunce in therapymiddotIn IODF tam t1I8tIIlti might nvea distinctioaa a recent IeView of research on ~ therapista to UIeful inctinical practice research aDd Uaimng develop BtlODg at1iancesHorvathmiddot (2004) reportCd Fourth weneed to esamme the sinDlarity and tbat _ than halfofthe projectll surveyed obtained a distinctivenea of the aIliaDcc concept compand to pot1tive rehnionship between alliance trainina and other relationship variables A recent state at the iIie quality of the s16snce a88C8Sed by the client or an art sutnmary of empJric8leVidenctl on the eOicacy indepeiadmt tater The review aIao iodiarted that middotof thcmpiau comlibudon to me therapeutic reIashyinVestigators were more amaistcnt in idcntifymg tionibip (Notcroaa 2002) dentified 11 relatiombip therapist attri1JuIa (swh u fleXibility inierest and faerors asmiddotpotential coDllibutOt8 to tbeJapy eOicacy warmth) than therapiatJ aaifJititIs anoclated With Alliance Cohesion Bmpathy Goalmiddot Conaenaua and positive or ImprOvina a1lianccs Itwas also notedmiddotthat Gollaboration Poeitive Regard ~~ all of the succeseftd training project8 Utvolved back Repair of Alliancemiddot R~ Self Dieclosure individual supcmsion of trainCes most oftpoundn within Counter lrmafcrence (managemeI1t of) and ]lelashyIi ItrUCtured format (of both superviaion and treatshy tional Intmpretadon The siamp1jfi~ overlap evident ment) aod these 811ccessfu1 training programs each among these middotelementa~J and the lack of a con-made use of the therapist currtnt problematic ceptual model knicentng these etementB iDto a cohesive relatioriahipwith their cU~ Tbeie fiDdinp ~ fiamework suagests that tlicre is a need tomiddot make tosoaest that it is important to more cl~ identify some c1atifkatiooa and distittctionJ shythe iiUeractive elemen1ll between 1berapist and client The time la ~ to renewrous cfia1o related to the alliance and we need ~ find methods - gue to clar1fy what we IQean by the concepts-Hated to identl1Y and manap therapists probl~reacshy abow What do these notions IIhare and wJurtuacful middottiona to cliema in order to improve tbeirmiddot~onal dietinctiona m8y be made betWeen them effectivenes (Beary amp StrUpPJ 1~94 Safran amp Mman 2000) Conc1uaimuIIbird we need to examine chaDgesio the qwdity cd the alliance over tJme The majorilJ of the The bqer ltoritat ofthe R8Carcb-on the tbcraiseutic available researdl iii based OIl the alll1JDlP1ion that Jelationahip is the ovcrarching goal of underaouKiiDg a posiilve alliance has the same quality overmiddotthe how thcrapyworll8 and of bull wbaJmiddot~ glean to

lengthmiddot of tteatmcrlt Pogressive enricbmem and - from a clearer ~emaadjog of tbe payclwtherapy crimplexi1J is a characteristic of all intimate rdationshy pf0Ce8S lCadmg to better practice The more we ship over time SO why should we 8I81lD1e that this is undentand how Cliems ab8Ob 1ItOre~ and retrievemiddot not the case in th~ The qualitiefof air~mem features of the telationahip with their thezapist and or consensus on bonds and tasks the formation of 8 usc itmiddotto ic-imagine -their aituation and- erpand tHe caring and tru8tfnC reJatioDSbip ~ even emeqence middot optiona they have Iavailable and the bCttet we of a coDabotativc 8fIJlce arc likely JeUObably unishy mulerlltand h(JW the therapiSt canmiddot aeate opportushyform requirements typicalofthe beginning phase of Dities to enbalcc 1bi8 proceea the znore We On the most tllerapics It is also EeaIOD8hle to 8atume that blanb in the puZzle of humart change lind groWth these issues retain SOIlle rc1evance in later phasesbull pzocesa But u the JdatiOlllbip evolves and becomes more As severalpapen inmiddotthis volume ilhlstrate research complex and III therapy evolYCII and the client on the relationship can lead us to better idcp$Y exposes more sensitive matetial themiddot ptooenes like patterlll that locate apecific ~~ wbichmiddot asreemcint on tasks and goals become ~ can fill important zaps in our understmding ofhow

embedded in the therapy routine itself It baa been thtrapy worbExamples of hmstiptions reported sugested (Horvath~ 2003) that qualities such III in this aectl0Il with theory builcUng poteDJia1Jndude

mutual reflexivity and the permission to critkaUy middot papers on how c]ientB interpret therapist bdJaviOl8

and mindfully engage in a discourse about the (Benecke et 11$ 2004 Cupat ft al 2004) cogniDve

immediate here and now relational pattern in the process that play bull tbrmadvc and maiotenance rOle therapy room may be more appropriate in discrimishy in forminc a poaitive icJadonlhip with the therapist nating the mature phase of the therapeutic alliance (casey ft at 2004i Rumpold et iI 2004 SextOn et

The lack of success in ident1fying what Bardin al 2004)~ III well as the identification of clinblly (1980) predicted u different [patterns of] alUancet impor1ant tre~ent chaJlensesspecific to pmsoashy

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z Psychotherapy Research September 2010 20(5) 526-534 R~-

The relationship between insight gained during therapy and long-term outcome in short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders

HAVARD KALLESTAn1JAKOB VALEW LEIGH McCULLOUGH3

MARTIN SVARTBERG PER H0GLEND amp TORE CHARLES STllESZ

I Division of Psychiatry Department of Research and DelJeiopment St Olavs Uniwrsity Hospitlll Trondheim Norway aDepartment of Psychology Norwegian University of Science and Technology Trondheim Norway 3Department of Psychiatry Harvard Medical School Boston Massachusetts USA amp Modum Bad 4Department of Psychiatry Diakonhjemmet Hospitlll Oslo NOTYJJay amp 5Department of Psychiatry University of Oslo Oslo Norway

(Recsiwd 25 JuM 2009 TnJUion ceilJed 30 April20IOj ~d 30 AprilZOIO)

Abstract This study examined whether 49 patients from a randomized controlled trial developed insight during therapy and whether insight predicted long-term outcome in short-term dynamic psychotherapy (STOP) and cognitive therapy (CT) for Cluster C pnonality disorders Videotaped sessions early and late in treatment were analyzed using the Achievement of Therapeutic Objectives Scale Patientslevel ofinsight increased significantly during STOP but not CT After controlling for early symptom change and early insight insight near the end of therapy predicted improvement of symptom severity and interpersonal functioning during a 2-year follow-up period These results support the theoretical asswnption that insight may be a factor in the change process central to STOP Within CT gain of insight did not predict long-term improvement

Keywords personality disorders process research psychoanalyticpsychodynamic therapy cognitive-behavior therapy

A meta-analysis has shown both cognitive-behavioral were associated with different psychological changes therapy (CBT) and psychodynamic psychotherapy to during therapy be effective treatments for personality disorders Tentative evidence that different therapeutic foci (Leichsenring amp Leibing 2003) A randomized and techniques can be associated with similar controlled trial comparing the outcome of shortshy changes in the patients experiences was proshyterm dynamic psychotherapy (STOP McCullough vided by Ablon and Jones (1999) They found Vaillant 1997) and cognitive therapy (CT Beck amp that although there were important differences in Freeman 1990) provided further evidence that both the delivery of interpersonal psychotherapy and therapies are relatively effective treatments for Cluster CBT characteristics associated with positive outshy

C personality disorders at termination and are assoshy come were similar in both treatments and described ciated with additional improvement during a 2-year patient characteristics (eg patient achieves new

follow-up period (Svartberg Stiles amp Seltzer 2004) insight or patient has cathartic experience) This

The authors also found that the therapy sessions in finding and the common finding of no differences

STOP and CT contained different interventions in in outcome between treatment modalities has led

theoretically coherent ways STOP therapists focused many to speculate whether different therapy

more on work with defenses and the transference modalities rely on the same underlying psycholoshygical changes (Lambert amp Ogles 2004) It is ofand CT therapists emphasized supportive stratshytheoretical and clinical importance to establishegies agenda setting and homework assignments

Although there was a demonstrable difference in psychological changes that are associated with posishy

technique we do not know whether these differences tive long-term outcome in psychotherapy and there

Correspondence concelflinyen this article should be addrtaed to HAvard KaUestad Department of Research and Development St Olavs UniYersity Hospital Postboks 3008 Lade 7441 TionClheim Norway E-mail havardkallcatadntnUno

ISSN 1050-3307 printlISSN 1468-4)81 online copy 2010 Society for Paychometapy Relelltcll DOl 1010801105033072010492807

~oIJMalichII (2008)bullbullbull689-103 0 7J1l1 Camhlidge Unlvaslly Prae ORIGINAL ARTICLE doilo1011ISJJ0332C1~1UiOO164X PrlMd In tbe UnIted Kingdom

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

P Knekttlmiddot O Undfonl T Hiirkinen M VilikoskiJ E Virtalal M A Luksonenl M MartNnlni

M Kaipainen C Renlund l and the Helsinki Pliychotherapy Study Groupl

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BlI(kgrolUld lnJuHiden1 evidence exists for a viable dwice between Img- and sholl-term psychodIerapies in the IrIIGtment of psydUaric disorders The preaenl trial compara the tlfectiv_ of one loog-tmn therapy IUld two IkortshylemI therapi~ in the lreaunenl of mood and anxiety disorders

Method In tbe JUbinki rydultlapy Study 316 outpatients with mood (gUtl) OJ lUIlIiety diJOOrd~ wu w

randomly ~ to thne treatment groups (long-term psychodynamic psychotherapy short-term psychodyrwnk psychotbetapy and solution-focused therapy) and were followed up for 3 yvars from start of treatment Primary OUbOlM measures were depressive symptoms measured by self-report Bed DepnlSlllon Inventory (lDI) and tlbservetshyrated Hamilton Depfll8ion Rating Sale (HAMD) and anxiety SfOPtoms measured by self-teport Symptom Check Ust Arudety Scale (SClAO-Anx) IUld OOserver-ratei Hamilton Arudety Rating Scale (HAMA)

ReeullL A statistkally significant reduction of symptoms was noted lor BDt (51 ) HAMD (3611) SCL-90-Anx (41 )

and HAMA (38) during the -year follow-up Short-lerm psychodynamic psychotNlrapy wu more Ilfedlve than loogtenn psycllodyJUllllk psychotherapy during the first year showing 15-21 lower scores for the fwr outco(M meuures During the lleCond year of foUow-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 man effective with I-h37l1 lower stIJfeS for the outcome variables No statistically $ignificant differences were found In the effectiveness of the short-term therapies

Condu5ioAs Short-term thempifs produce benefits more quicJdy han long-term psychodynamic psydlotherapy but in the long run long-term psychodynamic psychotherapy is superior to short-term thefllp~ However moN reseAKh is Itfeded to determine which patients should be giwn Ioog-rerm psychotherapy for the tteQbnent of mood Of anxiety diSQrders

RecdMi 4 Deamkr 2006 Rt1ised 29 M4y 2007 Alaquotpted 12 Jw1y 2007 fiTSl pubfWd Mline 16 Nooemkr 2007

Key words Anxiety depressiMlong-tmn psychotherapy randomized trial

Introdudion

Mood and anxiety disorders are prevalent and inshycapacilaling disorders that commonly run a recummt and lthronic course (WHO 20(0) Different psycho therapies short and long are widely applied in the treatment of thee disorders and therefore their efitctivenetIs is an important issue Clinical trials

bull AddrlB for ~eJ Dr P Knekl National Public HcallIl hwIIituk Mannahcimintir 166 OOJOO HelAnldlInlarn1

(1maII pauUneldOktUi)

have demonstrated that short-teem psychodynamic psychotherapy which is a brief focused and active treatment is effective in the treatment of mood and anxiety disorders (Anderson amp Lambert 1995 Barber amp Ellman 1996) tong-term psychodynamic psychoshytherapy which is a more intensive approach than mort-teem psychodynamic psychotherapy is widely used in ordinlUJ clinic practice The evidence on the effectivenll6$ of long-tenn psychodynamic psycloshytherapy is however limited and entirely based an non-randomized studies (Piper el til 1984 Wilczek

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Are psychodynamic and psychoanalytic therapies effective

A review of empirical data

FALK LEICHSENRfNG (lillie ofTielenbrunn and university of GOttingen von Sieboldslr5 0middot3707S Ollltingen Gennany

Fleichsgwdgde (Final version accepted 5 January 20(5)

17ure is a needor empirical oucome research in psychadynamic andpsychoanalytic thuapy HCM(lter bolh the approach of empirically supported th~rapjes (pound)7) and tile procedure~ of evidence-based medicine (EBM) haw SeIere limitaliol1S makinf randomised control Jed JriaJs (RCTs) an absofute standard Afiu a critical diSCl4ssiotl of his aplJrOach the autror reviews Ihe empirical (ltidence for the efficacy of pfdwtiynammiddot pschOlherap) in SPfctjic psychiatric disorders The review aims to icumtify for wltich psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available andJor which the) arlliacking thus pruviding Q basksor planningfilrther research In addilionfU[lS ofprotess~research ofwchodynamic pgtvchotherapy are prete~ methodology of RC1t is not appropriate lor psychoallalytic thINJp)~ effectiveness stztdies ofpsychQanalytic Ihuapy are reviewed as well Studies oJpsychodynamir psychotherapy puhlished beMeen 1960 and 2004 were identified by u compUlerised search I-fing Medine PsydNFO and Current Contents In addififln textbooks andjournal arlides were used TwenJ)-Wo RCTs were ielen ed qf which 64 had nol been included in the 998 report bull ambless and Hollon According to the results for the follOWing psychiatric dimrders at feast one ReT providing evidence fOr Ihe efficacy ofpsychtHJYflUlnic psychothuapy was identified dCprelSiw disorden fI ReTv) anxiety disordlry (I ReT) post-traumatic stress disorder ( ReT) somatojortn dLwroer (4 RCTs) bulimia nervosa (1 RC7k) anorexia nenoV1 (2 RCS) horderUtIt plrsollality dfOrder (] ReTS) Cluster ( personalit) disorder (I ReT) and fuhSll1nce-reliJIed disorders (4 RCn) According to retult~ (Jf process r~search outcome in gtchodynamic psychotherapy is r(llmedto the ~l11felenJ V deliITYOlherapeutltfec iques a to e Qpmen of~l7JfJ7Mic1JgDce With

7egWd to pihooiialfiTiiIiGapy controDed qUl1Sf6jiiiim~tmeS$ studies provide elidetflte lhat PSYChoanolYliC therapy is (1 J mOTl effectIe thall no treatHent ( 77fL r or treatment as Ilmal and (2) more effective than s1ltJrllr]ormi7JpsychOdJmamic ~~1 ~lIs1Ciisle drawtlfiJTflltllre rISf(lar- -- fJltJ ----

Keywords empirically supported treatments evidence-based medicine psychoWlalytic therapy pltychodynamic psychotherapy psychotherapy outcome and

process research

In these times of evidence-based medicine and empirically supported treatments there is a need for empirical outcome research in psychodynamic and psychoanalytic therapy (Gunderson and Gabbard 1999) In a first part this article presents a review of the available randomised controlled trials of short-tenn and moderate-length psychodynamic psychotherapy in specific psychiatric disorders As the methodology

C20M In~lIlue (lfrsycll(lDllRlysi~

-_REVIEW

Effectiveness of Long-term Psychodynamic Psychotherapy A Meta-analysis Falk Leicltsenr5 ~ S~n Ralruamp PhD______

THE PUCE Of PSYCHOANALYTIC and psycbodynamic trutshyments within psychiatry is contronuia11bulll Although

some evidence supports tbe efficacy of shott-term psychodynamic psyshychotherapy (STPP) for specific disshyorderslo7 convincing ttsearch on the outcome of long-term psychodyshynamic psychotherapy (LTPP) has bun huktngl18 Evidence suggests that short-tmD psychotherapy Is sufshyficiently effective (or most individushyals experlencing acute distress Evishydence however also ludicates that sbon-tenn treatmtDts are insuffiCient for a considerable proportion of patients with complex mental disorshyders ie patients with multiple or chrantlt mental disorders or personshyaUty disordtrsu Some studies sugshygest that long-term psychotherapy may be helpful for these groups of pltientsUOJ )16 This is true not only of psychodynamic therapy but also of psychotherapeutic approaches that are usually short-term such as cognitive-bellavionI tnerapy (CBT)nl6

Evidence-based treatments ror these patient groups are particularly imp01Wlt Personality disorders [or example are quite common in botb

For editorial cOlRtllflnt tee P 1$87

-----~---

Context The place of long-term psychodynamic psychotherapy (lTPP) within psyshychiatry Is controversial Convlndng outcome reseatch for l TPP has been ladcing ObJectIve To examiM the effects of LTPP especially In complex mental disorders Ie patients with personaIlty disorders duonic mental disorders muftlpIe mental disshyorders and complex depressive and anxietydIsordefs (Ie assodated with chronf(course andor mlAtipie mental dI$order$) by perfonning a meta-analysis Data Sources Studies of lTPP published between January 1 1960 and May 31 2008 weldentffied by acomputerized searth using MEDUNE PsydNFO and Cur-shyrent Contents supplemented by contact with experts in the field 5bIdJ Selection Only 5tudies that used individual psychodynamic ~otherapy lasting for at least a year or 50 sessions had l prospedIve deslp and reported reshyliable outcome measures were included Randomized controlled ttlais (RCTs) and obshyseNationai studle$ were considered Twenty-ttlntt studies involving a total of 1053 patien1s ~ fndtlded (11 ReTJ and 12 obIerva1fonai studies)

Data EktndIort Infonnatlon on study charaderistics and treatment outwme was extracted by 2 Independent raters Effect sizes were cafcutated for overaR effective ness tlrpt problems general psychiatncsymptorM personality functfOnfng and s0shyda functioning To examine the stabilityofoukome effect sizes wete atlculated sepashyrately for end-of-therapy and follow-up assessment Results Accotding to comparative analyses of controlled trialslTPP showedsignifishycantly higheroutcomes In overall efredIveness tarptproblems and personality funcshytioning than shorter forms of psychotherapy With reprd to ~aD effectiveneIis a betw~groupeffect size of 18 (95 confidenceInterval (0]07-34) indicated that after tratment with l TPP patients with complex mental disordef5 on ave ~ better off than 96 of the patients In the comparison groups (P=(02) According to subgroup analyseslTPP yielded slgnlfteantlarge and stable ~n-groupeffect sizes across v~ and partiadarty compfex mental disofders (ranse 078-198)

Co~ons There Is fMdence that lTW Is an effective treatment for complex menshyta disofders Further research sttouId addnS15 the outcome of LTPP In specific mental disorders and should include cost-effectiveness analyses JAM1OOBJ(lD(flJ1551middot15fi5 WWWjllmacam

IwIhorAffIIIIdIami OIpIItrIJIntgf~1II4general and clinical populations ~rIPJ uw1IlJ of OIlmen GfBuIn (()tThey show a high comoIbidUy with a ~and~of ModIcaI~

widt ran or Axis 1 psychiatric disshy Gp university Med1cal elllt Hall1blltmiddot Eppendori HiIrnbuJI (Dr~~orders and are significantly associmiddot t~IIII Autllot Flik lIlldueNlf Ok

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patients in cllnleal populations expe- AIftIoGel

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------Revi and Overviews

The Effectiveness of Psychodynam~c Therapy and Cognitive Behavior Therapy in the Treatment

of Personality Disorders A MetaAnalysis

Falk Leichsentlng DSe Ob~ The authors conducted a spondinsvalues were 100 2n and 081 metHlnaiysTs to addllU the effealveneD For more specJflc measures of personality of psythodynamic thetapy and msnitrve disorder pathology a amparp Oyenetall decEric Leibing DSe IJdtavlofthenlpy In the treatment of per- slm (156) WlS seen for psychodYRItIIlc sooalty disorders therapy Two CDp1ItIve behavior therapy Melhodl studies of~amlC lbGr- stuilles reported significant effetts for aex and iilnltlve bavlMtherapy tNt ITIOR spedfic mcasum of personallty disshywere pubfi3 iiampen 1974 Ina 2001 order patholoampvpoundg SdVnamc ~ were COllected Only studies thlit~] us8d apy the effect sizes1i1Otte iOnaterm standardIzed lIIdhods 10 dIagnoSe person- illiintetm ltsrw mnalshy~ allty dbordersij applied reIlabieand valid _ BY~lgdm Instruments tor the assessment of outmiddot Conch_om There is evIdence that mme and 3) reported data that allowed both ~ and cognIshyalculation of wlthiD-grOUp effect sIl2S or tlve behavior berjlpyen ~~e treatshyassessment of personality dborder ~ msn1I pi Rmona1fly dIsordels Since Itte ery rates were Included Fourteen studies number of studies that ltould be Induded of psydlodynamkthera py and 11 studies In this mlla1nalyss wellmlad the canshyof cOITlItJve behavior therapy were elusions that can be dnlwrl are only included iiiilijiry FGrtliif nUdia are necessary

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tl1l1ty interpersonal relationS and lmpulae control that me treatment or perso~ dbJorders psychodynamic therapy and cognWve bahav10r therapy Our revlew adshycalISe coDSlderabJe personal cOstreo (DSM-M (1 2) In dressed the following queet1onasubjects with pereanallty dIsorderaJ psychosoclal1mpelrshy

m811t and the we ofmental health resources is blgb (3-5) bull What 18 the evidaIlceofimproWmlWtiD symptomJsoshyIhe prevalence ofpat1enta with personality disorders in dal tunctiDnlng or COle psythopatbolosyafterpsychoshyInpatlent and outpattsnt psychiatric populattollamp Js h1gb dynamic dlerapy or cogD1dw behaviorrberapyf (eg the prevalence of bordedlne personality disorder Is bull Is rhere evldence of improvement In specific types of estimatedto be betlvasn In and 259(6)) Howevar there personality dIsordars after psychodynamlc therapy or Is aconampldemble ladt of emplrlcal research on treatment cognitive behbullvior themPJ of p830UUty dJaordets with psychotherapy with only a bull Do tndlvlduas w1tb pe8ODaUty d1sorder8 recQV8r a1ter few rando~ controlled studies (7 10 addreH CODshy paycllodynamlc dtmapyor oogoltlbehavior tberapyl eetnsaboutco8taofmentlIhealthservlce8emptrlcaldata bull Ate there d1tferences between self-report and obIIerwshyabout the efflcacy of psycholherapy In the treatment of tiona measwest personaltty d18order1 are needed filere 11 evidence that bull Is thete a comlaUon between outcome and duration of psychotherapy10 pneralll an eifective treatment for pershy tteatmentf Bonallty dIsotdll8 (7 8) but ex1ampt1nS studies indicate rbat bull What odler factors are connected wtm outcome (genshyoutoome may dIfter for dUfelent forms of psychotherapy derinpadent versus outpatient amptatull use of tberapy (910) IWd d1f1enmt peraonalltydlsoJdenl (n 12) manuals upetlenee of therapJats)

Am JPsychldtry 160fT july 2003 hftpIaJppsychIoUyoIllInampOIll 1

CIlniclll ~ Rmont VoLtl No So PI- 401192OD1 eoprigbt 0 iOOllllefter 8deDot LIdt) Perpmo Pr~ In die USA All rtahU ~

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PH BOm7S58(90)OOO5

COMPARATIVE EFFECTS OF SHORTTERM PSYCHODYNAMIC PSYCHOTHERAPY AND

COGNITIVEBEHAVIORAL THERAPY IN DEPRESSION A META-ANALYTIC APPROACH

Falk Leichsenring

Uni~ty ofGlJttingen

ABSI1tACT nil rptUI6~ 1MeJimcj o~~~ ($TPPJ in MJnasUm ~ 10 ~ thIrrIj (CBT) (If ~ (B1) r tAU ~ (m ~ iii tIIIampidJ alltmt 13 ~~IiIm~ Iaaw bam ~ _ GI iufJicMm 1UampMroff1aIJmtJ group rum tntaIItl (NI 2IJ) HttIamp JU1l to outaHIW criUritJ lhl tIIUbsfllllmr~for~ in ~~gtmmsl~~ msd~~ SUt _ tJui1ldurion eriIIIri4lWults In58 t1ftluJ6() ~ (91~) ~ ift tIuJ_~_~no~dijJimmu could fraquo~ ~ srpp tmll C11IlII emttImritag tJu fodI in ~~ IJfMGl ~ ~~ oft4 SfIdalfo~~ STPP _ CBTKI di411Dt tliffesipiftshycrmu midi 10 tMpatimts thal __juIfrKl tU nmdtkd CIr imJwowd A~ to fIIIItao

~~~R ampsmtIud (1991) tJusludiatlo tsotdiffir~ witA tit shygtml to 1M KIfMaII thtsI ftMlBtd ntIIittlaquolClr iwrfmJwtl ojtIr ~ tampIit1amp $TPP or CBII BT TM mlaquom tMffemau~ STPPmul CBTIlfI~tM~of~ tIiaItlMIf judpllJl mniItId ariWJ1rrlflld ~ to II mallffoa du ~ q = 00a foIshy

IlupwJ ~ q - 01) 1lnu~ STPP tJRtJ arrnrr11m 10 fraquo~f fIIdhlaquoJs in

~ crittt1ia 7IIfIll

lM tfrtJIpound~ HtIfIItIIIIi Cu ht _ 11 __x J04 ~ -~

I

Correspondena should be IlddreMed to Dr Faik Leichsenrlng University ofG6tlingen Departshyment of Psychosomatics and Psychotherapy Von SkbolOatr 6 1)-37075 G6t1ingen Cennany

40J

I

Short-term psychodynamic psychotherapy review of recent process and outcome studies

Andrew J Lewis Michelle Dennerstein Petah M Gibbs

Short-term psychodynamic psychotherapy (STPP) is a widely practised form of psychological intervention Given that the Roth and Fonagy (1996) review concluded that there was a lack of confirming evidence for STPP the current review is focused on studies published between 1996 and 2006 that evalllate the effmcy of STPP As a restJIt

i of a systematic literature review 18 studies were found that met inclusion criteria consistent with those used by Roth and Fonagy (1996) for selection of studies patientI groupings and definition of therapeutic method In general these studies add to an

1 increasing body of evidence suggesting that STPP can be an effective psychologlesl treatment for individuals experiencing mental health probtems Specificatly for depression STPP oan be equal in effects to other psychological treatments and is significantly better than no treatment in the short term Furthermore emerging process

~ data indicate that there is a significant relationship between the use of SpecifIC

psychodynamic therapetJtlc techniques and the alleviation of depressive symptomsE Jncreasing evidence has emerged to support STPP as a treatment for generalizedj anxiety disordar panic disorder and some personality disorders There remains limitedg evidence for the use of STPP treatment for patients with anxiety disorders that relate

i more to stress Very limited and inconclusive evidence currently exists to support STPP as a treatment for bipolar disorder eating disorders and drug dependency Future research needs to include broader assessment measures long-term follow up studies

I ~ tilat maintain an Identifiable focus and research that tndudes a fcxua on psychotherapy

process variables as they Interact with outcomes Key words outcome assessment (health care) psychodynamic therapy shon-term

i psychotherapy

Australian and New Zealand Journal of Psychiatry 2008 42445-455

Psychodynamic therapy continues to be a popular therapeutic approach among clinicians with 14shy40 explicitly subscribing to this orientation [12]

Andrew 1 LwIs SenJoc Uclurtr in P~hoJolY (Correspondence)

ScIIOII4 ~ facultJ of Ret Me4Idu NunIaamp ami lWIaiounI SdaKa Deld ~tr (Wecrfrolll C GeeloIII V(bull 1117 AUillralil Email udrewltwis4tuta

Mjchelk ~t~ Millef1 Sludcul Ittab M Gibbs Lt1lU1Or m P~holoiY

SdIooI of BtIIInlolllai uti SocW sa- ud Klmuultdls lJmnl1J ar Ballarat Bdanlt VlcrDrIa Aamlllla ~ivtd 16 kpkmber 2007 IICcqltcd 20 janUAry zooa

C 20011 The Roylll AlalUalian aIId New Zealand eonq at Paychialriw

But psychodynamic therapy is frequently criticized as lacking the evidence that would justify its use [3] It is therefore notable that during the last decade high-quality empirical studies have been produced that respond to this defidt The aim of the present review was to evaluate the efficacy of shortshyterm psychodynamic psychotherapy (STPP) using a systematic literature review of studies produced in the decade 1996-2006 The review is structured so that findings can be used to inform the clinicaJ use of STPP according to OSM-IV diagnostic cateshygories

~DI5bt Iht 1iIIIciIiIaulsmiddot ~32MDI$11iIO DC)( lOlOJ7om-~1I5

CLQtNl ~TIACBMENT T-o THERAPIST DEPTH OF IN-SESSION EXPLORATION AND OBJECT RELATIONS

IN BRIEF PSYCHOTHERAPY

BRENT MALLINCKRODT MARY JO PORTER AND DENNIS M KJViJGHAN JR Untv~rstty ofMwo~rl-Columbia

sttcenties explored attachment in A growiDg body of evi~ suggeststhat elishyrichotherojJy l~ 1M 1st stwJy clients cnfSmiddot adult attachment sty~may le animJoshy=38) in lime-liiilited tMrap)1 com- tant infl~ on the ~~odHrapy relationship

(for nmcwsace Mallildxodt 2000 Moyer amp the ExpelWlC8S rn Close Relashylonihips Scaleas a measure of adult jitachment the Ciient Attachment to fMraplat Scale (CA1S) Working AUishy

Inventory (WAl) and measures of

depth amJ smootuampess Cow-with J Bowlbys (1988) conceptof

a8Cllre base promoting greater apia- Ir cinachmmt to therapist

-

was asSOC1shywith iluecure therapeutic attach

1M1I1 CATS subacalu predictetl ~ique varianceln sesawnexperience not ac-1countedfor by die WAI alone The 2nd 8tJIdy was anew analysis ofdatil origishynally reported by B Mallinckrodt D - GanttandH M Coble (1995) Among women cUents (N = 44) who completed the CATS WAI and the Bell Object RekWns and Rlality Testing Inventory 2 CATS 9ubscales predicted unique variance in object relations clejidts not

accounted for by tM WAl alone

i t Bfeat Me11inekrodt Mmy Jo Porter IIId DcauIa M Xivbull the otheris ~m~ ~vated Beawsc

IIp-a Ir DeptrtcneIIt oflldOOatloua1 Scbool amtCOWlllel- hmnanoffspriDa are bam relatiVely hcJpleu and 1Ds~ Uo1YCrtUy of Miaaoud-OIlumbia this al~ period continues for several years

CtiaapoI~ve rcpdiDa tIIla ItIideIbouid ~ ~_ItD infantr~erPfOXimity iJ cmcial fot sumVlil -i Brem ~ PhD Ulliwnlty CJf ~ 16 Hm HIll young of oar distBDt BDCeStors proxshyr Cotuml8 ~mil Br-IIWl ~bIldPomioclu f ~

Pilkcmlamp 20(1) Howev~ tho recent ~ Psychological AssOciation Division 29 Teak Faroe ~ PSY~PY ~~pa CODC~ that ovuleDCe 18 aa yet insufllcient to make a clear jndgment bout whether custorrUziDI the therapy relationsbip to IJOOOW1t for cnem attachshyment style Could make a positive CODIrlbption to treatmeot outcomes (Ackerman et al 2001 p 496) In reapbD8e ~ the Task Forces call fot DlQI8 research we exp~ ~ follOWilltt tbcccreseanh questiOIla wfWh we felt were useful neXt steps in Ibo application of attachment theory to psychotherapy research Ca) Prom 1be starJd- pojnt of BowlbYs (1988) concept of licun bau for exploraJion is ~ security of a clients attachmeDt to hb or her tborapist associated -with tnClIe exteIWw ~-session Qlrrapeutic eJpIora- don (b) ~w clo8e1ydoea the Il118clnncm relashytionship between client and therapist miuor asshy pects of the clients otIJCpound cJose attacbnumt reIaIionships (c) Can ~ coustruct of client atshytachment to tbeiapillt explain SOIlldhipg nniq~ abOut tho psychotlierap process Of the client that is nOt explained by the working alliance

Jttach1Dellt 81 bull Seeure Base for amppIoratioa

B~ (1969 1973) held that from 8Il etboshy logical perspectiVe die auacJmwtt ofyouiiS chilshy

dmn totheir caregivers involves two behaviOral systcms--t proXimity-seekiDg attacbmeDt system and an exploratory system The two Iystems are complemenraiy in chat as one becomes activabJd

AmoDg ~ imity to categivets offered greater access to fOOd

85 I

ltd like to discuss what you do for a Iiving-taJk therapy And ld like to suggest something heretical-that calling It UUlIk therapY misrepresents and grossly undervalues what you do It may even mislead others about what psychotherapy is and how it affects people -Talk therapy makes it sound as if words Issue from your mouth or the clients and then dissipate in the air around you As If as the sayinggoes its cheap-ya know common stuff

WHATS TO TALK ABOUT

This is something live been thinking about for some time But the idea really crystallized for me a week or so ago I was at the Saturday morning Neuro-Psychoanafysls Lecture Series held monthly at the New York Psychoanalytic Institute New York University neuroscientist Joseph Lel)oux had Just made a presentation on the amygdala and the emotional brajn He focused on fear memories and how they are not just one-tlme inscnptlons in our brain Instead they are reconsolidated and rebuilt every time they are retrieved

WHAT REALLY GOES ON

As the discussant international neuroscientist-psychoanalyst Mark Solms PhD director of the institutels ~eurcrPsychoanalysisCenter pointed out this new view of memory suggests a way to get conscious control of a powerful but unconscious emotiongenerating system K f reconsolidatlonIf said So(ms opens the

eosslbUity of retranscriblng memories e e s w a really started a chain of tttougms in my brain He was talking about psychoanalytic therapy but he could have been talking aboUt any deepJy engaging psychotherapy Psychoanalytic therapy Is not just talk therapy but involves reactivation of the emotion Maybe we should call It transference therapy Through senSmvei ablY guidld discussion emotional merrtQ~es can be thoroughly processed --shy

THE SCENE OF THE ACTION

2

In other wdrds good therapists use transference-generated emotions to help a client leam new associations around a distressing memory They can do this repeatedly until the troublesome memory is extinguished This doesnt take place In the air Through the medium of talk the brain itself undergoes cha~ge Every time a memory is retrieved it is s ad ebulll in 11 kindler gentler-

s ona with what is going on at the time Genes snap to attention fancy neurotransmitters and nuclear proteins swing into action Nerve reactivity and circuitry Is aitered This ladles and gents is classy stuff and it sits right at the cutting edge of science

GOING FIRST CLASS

Talk therapy has privileged access to the brain It works Its changes on nothing lass than the cortex the thinking brain CognItive behavioral therapy for example teaches p$Opie to change how they monitor the environment so they do not need to emotionally react to everything negative that comes their way Brain scans show that talk therapy literally changes blood flow and metabonc activity in the cortex By ch~Jng the brain from the top down as it were It has facts1f1at last long after tile ihftra~s finished protectg ag~ [Iapse into distress in a way that drugs cant because they dO11shyeducate the brain _

WHEN ONLY TALK WILL WORK

So priviJeged is the access that talk therapymiddothas to the brain that sometimes its the only thing that works Last year a large multicenter randomized controUed trial of psychotherapy versus pharmacotherapy showed that talk therapy works In some 01 the most difficult cases of depreSSion for example whereas drug therapy does not It Is singufarty effective for those wtth 8 history of early childhood trauma such as foss of parents at an early age physicaf or sexual abuse or negl8CtPsYChOtflerapy may be an essential element In the treatment of dents with chronlo forms of m or depreSSion ana a history 0 childho traumaII tjle researchers repc In e -

l

Proceedings of theNational Academy of Sciences And it is so essential because some distressing memories can be safely accessed and reprocessed only via talk therapy

CAlliNG IT WHAT IT IS

That leads to the obvious conclusion It Isnt just talk therapy Dohe weill its brain therapy And yes mind therapy And emotion therapy Memory therapy And as Mark Solms said transference therapy Its all about the hottest thing In neuroscience today--braln plasticity I just want to make sure you are as much in awe of the magic you do as I am May wish you a very Happy Holiday See you next year Best

Hara Estroff Marano Editor at Large Psychology Today 115 Ea~ 23 Street New York NY 10010 212-260-7210 x235 httpwwwpsychologytodayeom

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Brief Psychodynamic Therapy With Clients With PD l( 1Itl P~~ A variety of psychodynamically based shorHerm therapies (fewer than

40 sessions) conducted with mostly Cluster B Cluster C and NOS PDs have been studied in eight randomized clinical trials yielding robust positive effects that have persisted at follow-ups averaging 189 months (SD =73 see the effect sizes of seven of these studies in Table 41) These include three studies that rely on Oavanloos (2000) approach as described earlier in this chapter Davanloos earlier method (before 1980) was found to be similar in overall outcome to two other forms of more supportive dynamic models and superior to a wait-list control group (Hellerstein et al 1998 Winston et aL 1994) More recently his technique has evolved to include methods to build anxishyety tolerance in fragile and somatizing clients enabling treatment of a far broader PO sample (Abbass 2002) A study using the current ISTOP model (Oavanloo 2000) found greater effects with a shorter treatment course than did Hellerstein et al (1998) and Winston et al (1994) even while including 12 out of27 PDpatientswith BPO (Abbass Sheldon Gyra amp Kalpin 2008)

A study ofCluster CPOs based on McCullough Vaillants ( 1997) model of brief dynamic therapy found positive change for clients treated in this modality and in cognitive therapy The dynamic therapy also brought a sigshynificant decrease in symptoms which was not the case for cognitive therapy (Svartberg Stiles amp Seltzer 2004) In terms ofstrategies this psychodynamic therapy uses defense affect cognitive and self-other restructuring as described in the Mechanisms of Change section

In a different study another form of time-limited manualized therapy known as supportive-expressive therapy (Luborsky 1984) which is based on standard psychodynamic principles was compared with community-delivered nonmanualized psychodynamic therapy conducted with clients who had Cluster CPOs both yielded comparable positive results (Vinnars Barber Noren Gallop amp Weinryb 2005) Finally brief relational therapy (BRT) was compared with brief dynamic therapy based on standard psychodynamic principles and with cognitive behavior therapy in clients with Cluster CPOs and POs NOS (Muran Safran Samstag amp Winston 2005) The results indishycated that the three treatments were equally effective although there were fewer dropouts in BR T The strategies used in BR T are to track alliance rupshytures and to communicate about what is happening for client and psychothershyapist thereby cultivating awareness of self in relation to the other

These data gathered from a group of reasonably good quality studies from several different research centers offer empirical support for short-term dynamic therapies for a range of POs They do not however indicate the superiority of psychodynamic therapy over other therapies

() HAAVCUJlf-(Cd) 0v~-bCLseJ ~fmeu- of u _ C EVIDENCE-BASElPSlt~ODYNAMIC THERAPY 101J P-tVt9c11 Of) f7JD 1-G- III )~ WiLSlUAi-~rtvt)IlX-t AfA

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TABLE 41 Treatment Descriptors and Effect Sizes (ESs) of Brief Psychodynamic Psychotherapy

~ tTl Randomized Clinical Trials of Individuals With Personality Disorders (PDs) Mean length ~

PD diagnosis Mean total follow-up SCl-90 BSI Study STPP intervention N (clustertype) sessions (months) orGSI ES liP ES GAFES~

Ei to 2

Abbass Sheldon et al (2008)

Hardy et al

ISTDP (Davanloo 2000)

Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226

(1995) interpersonal (Hobson 1985)

Hellerstein et al STDP (Davanloo 25 A B and C 29 6 027 031 (1998) 1980)

Munroe-Blum Dynamic 26 Borderline 40 24 092 et al (1999) psychotherapy

(Kernberg 1975) Svartberg et al STDP (McCullough 25 C 40 24 095 104

(2004) Vaillant 1997) Vinnars et al SE psychotherapy 61 A B andC 26 24 063 068

(2005) (luborsky 1984) Winston et al STDP (Davanloo 15 A B andC 40 18 058

(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1

Note Effect size was computed by dividing the pre versus post score difference by the pooled standard deviation Data from the longest follow-ups were used to calculate the mean treatment effects Effects sizes of 02 are smell those of 05 are medium and those 08 and higher are large An eighth study Emmelkamp et al (2006) did not use any of the common measures listed STPP =short-term psychodynamic psychotherapy Sel-gO =Symptom Checldist-90 BSI Brief Symptom Inventory GSI =Global Symptom Index liP =Inventory of Interpersonal Problems GAF =Global Assessment of Functioning ISTDP =intensive short-term dynamic psychotherapy STOP short-term dynamic psychotherapy SE =supportlve-expressive Dashes indicate that no data are available

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Do Comorbid Personality Disorders Moderate Panic-Focused Psychotherapy

An Exploratory Examinatio~ of the American Psychiatric ~ociation Practice Guideline

Barbara L Milrod MD Andrew C Leon PhD Jacqu~ P Barber PhD John C Markowitz MD and Elizabeth Gral MA

O~c~ lbtAmerican Psychiatric AsSociashytion (APA) practice guidelina for panic ~ recommend8 p8ycbodynamic psychodlcrapy forpanic cIiIcJrdor ~ wid comotbld pcmmaJity disonhn No data underlie thi5 recommendation Tbia erpIoraJory study allCllCd die uiodendng cft1ct of penooality disorder on psychodynamic and non-psychodynamic paychotharapy OQtoome

MduNl Porty-niDe subjects with primary DSM-IV paaio dillOtlklr were randomly llllipod 10 12 wcclca of twice--weekiy Pani~Pocused Psyshychodynamic Psychotherapy or AppJie~Relaxation Traitdng11le primary outcome measure was the Pmic Dlsordlaquo Severity Sltale the modmaIilll efftiGt of Aba II psychopathology Oft he Sheebaa Disability Scala was IIlio tc8ted The trial W8I coaducted between February 2000 and January 2005

RJIl16 1weoty-f01lt subjects (49) met OSM-IV criteria for a Structured ClinicallDtershyview far DSM-lV Axil nDisordera-diaJllOsed

-personality diIorder of whom 1~ CZ21l had bull c11Atpound~ Presence of a cluster C 1i nOli edt trea1meDt outcome stlcii au jeoos oxperiCliampd geiiiiffiPiOViampiiii In Piiiicshy

f~pre1sectifsect~ shy~ IJI1IU sample 81ze~ this exploratory analysi8 provides initial prelim nary cvideRcc CCfTOboratins the APA practice JUldelino reco~n Future panic disorder clinical trial bullbullhould explore Am n moderator cffeoIi

ClWcfIUrl4b Regillltltltgtlll QinlcalTrltbIIOV identitler NClOO128388

(J elln P syclrJatry 200768885~1)

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T1te ardhor 1CpOI1 tItIdJtUwIlflNmclll or DIIuIr ~ 1tk1lGlll1D 1M NbJlaquor rf tAU tllllc1L

COIfUJH1NlIIaI talIrDr tIIId nrprbtll BarlIrza L Mlltod MD ~~P~ WooiBMttdlcol CoIl ~COl7Wll ~ky S1J ampIIIl6amplt St NN YDTic Nt 1()(J21 (NIttlII ~cor-UuJ_

T he intcncction of the DSM Axes I and n poses a clinkaJ chaUenae When clinicians disoover

personality disorders comorbid with Axis J diagnoses should they alter theiT treatment approach Are particular therapies more or less likely to benefit patients with mulshytiaiial comorbidity1 Unfortunately this ~ has received re1ativoly little attcotion especially in anxiety disorder patientamp The Axia n comorbidity of panic disorder is an interesting example III many patientl with panic disor- dcr also have Axis II diagnOBCll particularly in the (anxshyious) cl~ C

In a descriptive study Ozkan and Altindagl found panic disorder patients with comorbid personality disorshyders bad greater clinical severity tlCIOU anxiety mood and psychosocial domains than panic disonier patients without personality disorders Few studieshaveexamined the effect of Axis II on panic disorder treatm~ outcome In the naturalistic moltiaite Harvard-Brown study (N = 514) Masaion et al1found DO negative impaCt UIIociated with comorbid personality disorderamp diagnosed by Intershynational Personality Disorder Examination on time to panic disorder remission Another report foWld cluster C

disorders were associated with longer duration of panic disorder4 potentiallY confiating apparent moderator efshyfects of clUJtel C disorders with panic disorder duration an identified indicator ofpoor prognosis5

Studies of Cognitive Behavioral Therapy (CBT) for panic disorder have reported mixed effects of Axis n

885 IPYRIGKT 2III7IMY8ICIANS POSTliRADUATE PRESS INC COl111lHT 20117 ~~~~i~~7

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EVALUATING AN ALLIANCE-FOCUSED TREATMENT FOR PERSONALITY DISORDERS

J CHRISTOPHERMURAN Beth UTJI8 Medical Center and

AlMn Ebutein College ofMedicine

USA WAUNBR SAMSTAG ~ I Umg 1sland University and

Beth I~l MIdIcal Center

r This paper pnsents a study with the raquo aim 0ewJ1uating the nlativ~e

of liancemiddot ed t11 ~ atlonal theran conrpariaOll a s ic therapy and a cognitive-behavioral therapy on a samshyple ofhighly c01J07bid personality disshyordered patients Results indicated that thl three treatments were equally effecshytive on standard statistical anaJyses of change including those conducted on repeatsd measures and residual gain scores Some significant dijferencu

1 ~ Yunm DcprtImeiDt of~ BlaquobrshymI ModIcIIJ CcaIar IIICl Albert BiDI1IIiIt CoDep otMedldM krauy D 8drm ~of~Nn Scbool 1hIiveoUJ md J)paramIIIrofPlycblltryBeth rI Nadical CeaIer Ua Wil1DIr SamItaamp J)eputmeal of 10amp7 Lcq IIIIDd UalWIIIIty III Brooilya IIIId J)epl1 tJI chiaII7 DedI JuIIll ModlctIl CeafIIr md AaIold WlDItoD

DepIt_ of~ BedlI1dol Wtdical CcaIar - AlbeIt IIiDIIIda ColIIp ol ~

The ~ I1IJIPOIlId fa pIlt by fRIm tho Natblal ampa1ItulII of MIIIUI Health MIUOl46 It WII pDshy

IeQIIId It IboamJeIlIIOCtIDamp tIC SocIetJ fat ~ ~ sm BcbIrI CalIfcmla JUlIe 2002 W1riIh 10 IICblowledp tho ~ of BIDDaId S GOIDllIIlIIIId II 0Uf l-mh __ III IIdditioa _ waa1d

ampleo JIb to thaDt our copkI~onllllplllyeniscD JtI l1Dza TI1I1lIif BIIDbe1h Ochoa ad PIJIly ScIm1coe our abcrt-tmm dyMmic lUJViicn10amp01II6 PollIck tIieBaBtf ad MlcbMl LIIkID well aD tile ~ nd patieI1II wbO puticipatIld ~ cooccndraquol IhiI erlkkl sbov14 be lidshy

dnaId to J ChJlItopber M1IIIII DIIh ~Medical Ceater lim AftIl1I8 at J6th SUCCt New YQIk NY 10003 BmiddotmaD jcmBreIl~org

532

JEREMY D SAFRAN N(IW School Unlvenlt and Bcth 13rael Medical CmIer

ARNOLD WINSTON Bm Israel Medkal Center and

Alben EinstmJ College oMedldne

were indicated regarding clinically sigshynificant chtmge and reliable change favoring the brie rellltUmaZand cognitive-behavioral mode TMre was also a significant dtJference reshygarding dropOut rates favorlng brief relational therapy

Keywords therapeutic alliancc pcrscmshyality disorders brief psychotherapies treatment outcome clinical significance reliable change~ dropout status

Mucb has been written about the limited CCOshylopal validity of tl1c rcscaroh on lllIIllJ empirishyca11y supported treabXlents that have been tested largely on pa1ienta with very circumscribed diampg DDStic profiles and pdmarlly Axis I conditiORllIaI_ (d Elliott 1998) In their cridcalJeVicw of1mshydomized clinical trial 8bld1es Weshm and MOlshyIieon (2O(1) found that the czclualcm l8Ir8 of patients who presented with multiple dlagDlJiICamp lypically nmgcd from ~ 10 7096 Tho vaal JDl90dty of patioots that aedr treatmeat in our mental health cliDica Ol priIIdC pradiccs h0wshyever do present with ~Ic diagDoses with estimates of comorbidity nmging from 4ft IQ 709amp (see Kculer ct aL 1994) lb1l8 1he eDIDt to

Which me peat body of peychodletapy reaearcb conducted on sinJly diagnosed patienta is releshyvant 10 practice in ftlampl-world settiDga is arguable

In contrast the empiricallittrature on Iho treatshyment ofgtpersonaUty diIotden (BatelnaJl cl PoD- 18) 2000 Crits-Christoph 1998 Perry LiDsshyiardi amp IIDhi 1999 Piper I royce 2001 Shea 1993) which is growing but remains limited in

----~Theory~ T 0201O~II~A~111)0 Val 41 110 4 6ll-64S 003~IIIISI1OI) 1lOI 1IIOl7hoIlMII7S

DROPOUT AND THERAPEUTIC ALLIANCE A META-ANALYSIS OF ADULT INDIVIDUAL

PSYCHOTHERAPY

JENNIE SHARF LOUIS H PRIMAVERA Pace University Counseling Center Touro College

MARC J DIENER Argosy University Washington DC

This meta-analytic review of 11 studies examined the relationship between psyshychotherapy dropout and therapeutic alliance in adult individual psychothershyapy Results of the meta-analysis demshyonstrate a moderately strong relationshyship between psychotherapy dropout and therapeutic alliance (d = 55) Findings indicate that clients with weaker therapeutic alliance are more likely to drop out ofpsychotherapy The meta-analysis included a total of 1301 participants with an average of 118 participants per study a standard devishyation of 115 participants and a range from 20 to 451 participants per study

------_shyJennie Shad Pace Univemty Counsetinl CmlIU Pace

UIIi~ Louis H Primavera Oraduate SChool of Psycholmiddot ogy IUld Sdlool of Hea1tI1 S~ Touro College and Man 1 Diener CUnICll PsycbolollY Proampwn Argosy University Wuhingtoo DC

Ibis paper is balled in pan OQ tho Derner luIitute of Mvmced hylt~ Studies Adelphi Uoivcnitj doctoral ~ of Jamio SbIrf An utIiec vaaion of Ihla llUdy was ~ lit tho 8lUIull meetilll oflhe AmericuI ~ lop AssociItIoa BosIon Aupst 2008 Th6 IlUIbon atlI

graWvl to tbe Editor Dr CIwIes Gelso mil the lIlIOQymoll$

reviewm of this maDIlSCript for thdt be1plI1 oomJIIOnll amplid SUggWlODS We thank Dr tUbn JoIwIIson Dr William Piper and ClIrIos SiemI for proYidiIll additioQt daIa from several odampinal slUdies We also thank Dr ~ Shick TryoI fOt her helpful rocommenltlaliOIlJ We are alto aweM to Dr Micbacl Boremmo for his swistical consultation

ComspolldeDCe reptll thiI article should be ~ to lennie SIIad PhD Pace Univusity Counseling CaIre 156 WUllam S~ 12t1l Floor New York NY 10038 8-mall jsharfegmailcom

Exploratory analyses were conducted to detennine the influence of varitlbles moderating the relationship between alliance and dropout Client educashytional history treatment length and treatment setting were found to modershyate the relationship between aUiance and dropout Studies with a larger pershycentage ofclients who completed high school or higher demonstrated weaker relationships between alliance and dropout Studies with lengthier treatshyments demonstrated stronger relationshyships between alliance and dropout Inpatient settings demonstrated signifishycantly larger effects than both counselshying centers and research clinics No significant differences were found beshytween client-rated therapist-rated and obsenerlstaf-rated aUiance Recomshymendations for clinicians and researchshyers are discussed

Keywords psychotherapy dropout preshymature termination meta-analysis therashypeutic alliance working alliance

Supplemental materials httpdxdoiorgl 1O1037aOO21175supp

The most recent meta-analytic review of the psychotherapy dropout literature (Wierzbicki amp Pekarik (993) found three client demographic

637

~~~ ---------------~ ~~~~-----

The Efficacy of Psychodynamic Psychotherapy -----------~---~-~- shy

Jonathan Shedler

bull empirical evidence supporrs rhe efjicacl of Isycnod)namic (herapy Effecr gti1lt1gt foy psyciwJrnamlc Ihercrp are us largt 2 fhou ~eporud f(lr Qrlur Intrapies thar hawt iJeen O0lillIJ) promoted I1S lmpiricaii supporled arid middot(lvimiddot detlC( based [1 addirioll pareJ who recee psycilOdymiddot mImir hfltJjJY mairlOtn rhempeunc golns GIld appfar to coilil I) improc afrr rtcul7lefJI c1ds Finally nonpsymiddot d dunur Iu apltl 1iClt) be eJeiIn In pari becaLJe rite IIm skilled practiriol7ers wilile ieurochnhUer that have lOll-ii b~~J (elllral II psycllOd) numic h~o) and practice The pprnpfiorl hat pSfiodlnamic Ippmacles lack empincal Hltpport does 110r accord with aIaiable scientlfk eVidence (mi moy reffect slieclie disuf1irwrioll (~f reJearcn findshying5

psyclOtherapy OUCOffie p~ychoherapr procesli psycholnal~is psychorlynampmit thetapy metashy1lJl81ysi~

Thcre ~ a bchcf in ~ome quanel that psychodynilmlc conctpttl and treltments lack empirical sUPPOll Qr thaI scientific evidene shows that other fonus of

treatment are more effective The belief appears Ie have taken on l life of it~ own Acwlcmiclangt repeal it to one anoilier as do health care admini5traton as do heaith care policymakers Wilh arh rip~tltion lts apparent credibility grows At some pomt there seems h~tle lleed to qlestion or reviSll II oocaus middotevefone knows Ii [() be S0

The ~cjentifi( evd~n~e teh a different story COMldmiddot erable f~clJh ~UPPQ1S me efficacy and effectiveness of sych()dynamic tlC13py Thl dicrepancy between percepmiddot tiolls and evidence may be due in pari to biaseG in the dissemination oJ research findings One potential source of bias lS a lmgenng distaste in the menial health profe~gons for paSl psychoanalyu( arrogance and authority In decades Pilt American psychoaoalysis middotas dl)minnted bli hierarmiddot cillcal medicai eSIlbli~hment Llat demed training 10 nonmiddot MDs and adopted a dismissive StSlle toward researltn This stfJllte did nOI win fnends in academic circles When emshypirical fmdjng~ emcfSoo lhal 9upprrred nonpsychodynami tnatmeIIS many academicians greeted chern enthusiastimiddot cally and were eager to dis(u~s and di~ampeminate them When tomplIical eideTlce Fiupported psychodynamic canmiddot et~ and treatments it was often overlooked

This article bnngs IOgether nndillgs trom several emshyplrical literatures tilat bear on the efficacy of psychooyshynamic treatmenL I tirst Clutline the dbtmcivli feature~ of pS~ih0dymlmc therapy I next r~lell emprical evidence for the effi~(lcy of pychodynsl111lt treatmenl including evidence thaI patients hl re((lgte ps~chodynamic therapy 1101 onlv maimain thcmpeutic gain hut ofltinut to imrrove

98

Univeriry of Coiorado Denver School of Muii( llIe

over time Finally I con~ider eVldence lhllt Ilcrpsyiwd namic therapies may be effecthe in part becauC th rr) ~killed prllCtitionere utilize interverHiollS thtll hllve k1 been central to psyclwdynamic theory and j)flnt(

Distinctive features of Psychodynamic Technique

Ps)chodynanllc or psychoanalytic pspholhfaf)Y tvs to a range of treatments based on concepts and method~ bal involve les and may be considerably briefer than pydlOnaly proper Ses~ion frequenc) is typically once rof tWICC pc week and the rreatmenl may be either time limited -Ir (IX ended The es~ence ofpsychodynarnic therllpy i~ ~xplorll those aspects of self that are l10t funy knowa especiltil~j they lITe manifested uld loiemially mfluenced in the dw apy relationship

Undergraduate tettoooks too often equate alytic 01 psychodynamic tnerapies with some 01 the mo outlllrdiltih and inacceBsible splculahons mad b~ Slgmw Freud roughly a century ago rarely presentinl m3in~tre psychodynamic concepts as un(uStooc and pn) lccd I

day Such presentalions along with caricatured dcpictifgt in The popular medin hiIVe contrIbuted to Vide~rlflad mi understanding of psychodynamic treatment (ft)f i~ui of how clinical psychoanllyslS is represented an j micre resenteci in undergraduate curricula see Bormlltin i 98shy1995 Hansell 2005 Redmond amp Shulman 2()j)X) ro lid dispel pOSSible myths and facilitate greater mUIstdIHh of psychodynamic practice in tilis ccuon I e I~ features of contemporary psychodynamic technique

Blagy and Hilscnroth (2000) conducted d ~earc1 the PsycLit datllbae to identify empirical ~ludic htf pared thE process and technijue of munualz~d pydt()J l1amic therapy with tha of marlUlllzed therapy (CBT) Selten features reliably chodynamic therapy from other therupies 8pound dcr()flntd L

empirical examination of actual session recordill an

I IhrlOk MIITK HHsenfOlh fo his exen~ie ltxmlnbulcn) to Inr Jf1~

Mm Dten~ fer ptoliding lOrne or tho inrOmlill(If tepo1ed tcentr Ro FeM$lelr OM Gsbbarlt Michlel Kmon Kenneth Lej ~ J M lilmslohen Michel G~orgc Smc~er anll 1()gtell Wale fe I C)ffimems on draftS of tl1c lIftlcle nd t~e mmtgtrr 0 gtshy

P5)c~odynQmc Rc~8rch LiiI$UY Ii) their wi-d1 ~nd port

Concpolldcnc COOt5rt11ag Ihis 1f1ke innud ~ itJlP

tp JOrlthar Shoclampr Depattlllel1l of Pychi~try UVCI nt C I

ado D bull School of Medicine Mil SlOp AOJ~ 1)[1111 F Plae~ Adt~r CQ ~OQL$ amp-011 (gtIIh~rihhlldlt riCn

I ~ he (Urn 1chorJlIltrrlc ~rdnl)c~odwlllmi( m~dli~l

February-~1arch 2flHI bull ArnericlUi Pgt hltJ1Jb () ltH~

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Article

Randomized Controlled Trial of the Effectiveness of Short-Term Dynamic Psychotherapy and Cognitive

Therapy for Cluster C Personality Disorders

Martin Svartberg MD PhD

Tore C Stiles PhD

Michael H Seltzer PhD

(

ObjedMH This SlUdy compalid the dmiddot fectMnas of short-term dynamk psych0shytherapy and cupitive thrrapy for outpashytients wtth duster C peflIOnality disorders

MeIhod Patients (N=50) who met the criteria Ivr one or more duster C pers0nshy

ality disorders and not for any OItIer pershysDnallty disorders were randomly asshyslsned to melve 40 W~ _1)1 of short-term dyam1c PlYotberapy or coanldvethrraW The riA tbtIImon axfs I dlSUilSift In tne Pilent IVOUP were an Iety and depression dtasnoses Therapists _re ecperienccd fulftfme dlnlclans and _re rectlIIfII manllal~~rvf sfon Outcome valblbles Indulled sympshytom distress InterperSonal problems and core personality pathDlolY Measurea wen administered repeltedJy dunns and after trbtment anef chance was assessed 1onsWdlnally by means of growth modelshyI pro(Hurcs

Results The owraIr petIettt IICUJ) showed on average statlstlcallv sil1lf1callt ImshyPltMlnenb on bullbull measures amptvrlna treatshyment and also dutlna 2yqr follow-up

Thecluster C dIaordm 11m the DIOtt pnmlent penonshyaUty cUaolderl in the gIll8l8l population (1) (one of 10 InshydMduala) and In~ cIbl1c populasectns tID (mom thm one of tWo ~MbfidiiiiI the presence of InY cluaterC pmonaUtydiaorder bmrlahly uaoc1atedwfIb poorer outcomes In the treatment ofala I diaordera (3-5)

In JJtbt of theae find1 it bull pualfng to flnd IUch B

1audttofmntmlJed trilamp UJllmns the e1IectMmeu of IndIYlduat ~ in thIt popqlltlpn ~ng1he handful ofstud1eI that have been condwled only one (6)

canbe~ aa aWldomlzedcoD~ dfically dealped to way the course or these dfaordera dwiDland atter treiiDiilit In thai1_8Ipatients with ~ cmeter Cdiaorden (7OIL) mowedrgom cant and equtvalent tmptollllmllnt on mea8llIft of~ and8Oda1functlo1dDgafter40aeulonsoftwo forms ofdyshynamic ptycbotberapy Furthcnnine treated patientI did alpIfbntlybetter than wait-llat coUlparl8on 81lhjecta and pins WfIre malntalned at 15-yiu tanow-up In two

810 htIplloflPJIIChiGtI)onIlne013

period Significant Chanl~mptom~ (dlstnID_~weAJ forS v

ItOUP Of jiitlirili Wh9 tiIampiM DIOFRifJnf

ilYiJiiil1c meral) LUinOtlt0~e qnltfw patients DiSp e dwrenca rnmiddotjntliifQup chanees no sta- tfstIiairy SiiflifIWrt CIJffeteiiQ bfifWin V 011 IrRIllMerm dYMiMlc pytnotMlipy

IOUp ana WifidMlltIMfJt puIS Iraquom tWfid on Iny MamA Ib itiY tirinl pi l

-nOil I IItel tidtiiiem5496ofChe short-term dynamic psychotherapy pashytients and 4~ of the COIfIltIIfe therapy patient had reawered symptomatkJlIJv whereas approximately 401tt of the pashytients in both groups had rtCoveted In terms of interpersonal prOblem4uld per sonallty funcIionlnc

eraquondualons Both short-term dynamic p$ychoth4tFapy and lsnltlo theltlpy I have I place In the treatment of patienf5 with duster C personality dlsordm Howshyever fIIctors other than treatment modal-Ity may discriminate better between sucshycessful and poor outcomes SUch fadoll should be explond In future studies

~J~~ 11t1fUJ1J

addJtlonlll zandomlilled controlled trlala data for subshygroups ofpatlenD With predomlnantly cluster C dlaon1em were analyzed separately witbln IarJer1dals designed to study major depMsaton (S 4) The ItUdies found tbat pashydtDtll withptmIODIl1tydisordm responded equaDywellto InteIperaonal paychotherapy md cognlttve bebavlor ther ~SPJ (S) and equallyWBll to psychodynamlc-lntelpelloDal ~ ~ therapy and cognltiw behaviorthempy (41 Pinall In oneOb middot uncontrolled study sa patient with obseutve-compul- p ~ amt ailOMintpenmnaJity disorders treated with time-

lIm1ted aupponiezpresslw therapy demonstrated aig- n1flcant average chances on dIagnoetic meuwea and on meaamp1IeI ofdImuI ~ problems andpetlODo

alltyfuDCdoning tn 1bepresentatudymcmda tbcatudybyWimtonetal (6)

by eumiDing the effects of O-session ahortmiddotterm elyshyJWI1k psythotherapy apeciflcally destpedforpenonality problelJll (8) and comparing thoae dec1B not with mshyother form ~dDlDlfc tbexapybut with an al1amame apshy

11m Psyddotry 1615 May1004

Elii Child AdaIeK Psychiatry (OO7) 16tS7-167DOt lGl00sOO781-006-OS84x ORIGINAL CONTRIBUTION

Judith TroweU nan Joffe jesse Campbell Carmen Oemente Fredrik Almqvist Mika Soininen UUa Koskenranta-Aalto Shena Weintraub Gerasimos Kolaitis Vlassis Tomans Dimitris Anastasopoulos Kate Grayson Jacqueline Barnes John TIIlantis

Accepted 14 October 2006 Published online 1 January 2007

Original lead r~(her Prof 158Y lltolvin (deceased

I TroweU MBBS OCR DPM FRCPsych (~) Pro(mor or Child Mmtal HWlb West Midlands NIMHEICSIP Honorary Consultant Child amp AdollSCml Psychiatrist Tavistock Clinic 120 Beiliu Lane London NW3 5811 UK TeJ 01701 652205 (UK) poundMall judilhlrowelljcsnetcouk

I roffe MRCPsycn Hertfordabire Plrlner$hip NHS Trust lthOd amp Family Clinic MarloweB Health Centre Heme Hempllead UP1 HIE UK

J Campbdl Tavislock Clink 120 Belampie Lane London NW3 5BA UK

C Clemente MRCPsych Royal Free Hampstead NtiS Trust Department of Child a Adolei(ftlI Psychiatry Iloyal Free Hospital Pond Street London NW3 3DP UK

F A1mqvist MD PhD M Soininen MD U Koskenranta-AILIto MD S Weintraub MA Department of Child Psychiatry The Uospital ror Children amp Adolacents tlaculty of Medicine University of Helsinki Lastenlinnatie 2 00250 HelsinkI Finland

Childhood depression a place for psychotherapy An outcome study comparing Individual psychodynamicpsychotherapy and family therapy

II Abstract Background Although considered clinically effective there is little systematic research confirming the use of Individual Psychodynamic Psyshychotherapy or Family Therapy as treatments for depression in chilshydren and young adolescents Aims A clinical trial assessed the effecshytiveness of these two forms of psychotherapy in treating modershyate and severe depression in this age group Methods A randomised control trial was conducted with 72 patients aged 9-15 years allocated to one of two treatment groups Results Significant reductions in

G Ioiaitis MD D Anastasopoulos MD J Tsianti5 MD DPM FRCPsych Departrnmt of ChUd Psychiatry Agbia Sophia Childrens Hospital Athens Univec$ity Medkal School Thivon amp Lewdlu 115 21 Athens Greece

V Tamaraamp MD Department of Psychiatry Eginition Hospital Athen$ University Medical Shool 72 Vas Sophil$ Av 115 28 Atheru Greece

K Grayson BA Ms FRSS Statistics By Design 6 Soudumpton Close Blackwter Camberiy Surrey G UI7 OHB UK

J Barnes SSe MSc PhD IMUtule fOf the Study or Children Families and Social Issues 8lrkbeck Univmity of London 7 Bedford Square WCIS 3RA UK

disorder rates were seen lor both Individual Therapy and Family Therapy A total of743 of cases were no longer clinically depressed following Individual Therapy and 757 of cases were no longer clinically depressed following Family Therapy This induded cases of Dysthymia and Double Depression (co-existing Major Depressive Disorder and Dysthyshymia) There was also an overall reduction in co-morbid conditions across the study The changes in both treatment groups were pershysistent and there was ongoing improvement At follow up six months after treatment had ended 100 of cases in the individual Therapy group and 81 of cases in the Family Therapy group were no longer clinically depressed Conshyclusions This study provides evishydence supporting the use oifocused forms of both Individual Psychoshydynamic Therapy and Family Therapy for moderate to severe depression in children and young adolescents

II Key word5 treatmentshychildhood depression individual psychotherapy shyfamily therapy

II( w

- ~~~mraxm PubliJhecl 0IAIiNt in WiIay ~(IfWW~wlleacm) DOl lOl002cpp530

Who Can Benefit from TimeshyLimited Dynamic Psychotherapy A Study of Psychiattic Outpatients with Pers~nality Disorders

Do Virmals1- Ja~ues p Bub~S Kristina NO~l Barbro Thormlhlen2 Robert Gallop Amdka Lindgrent and Robert M Wehuyb1

1Deportmmt of ClinictIl NtIUOSCielue ~ StcHtm ~ Institufd Stodholm Srmien I Deportmmt of N~ DlvtJifm oj ~ lCImJIi InstitJdtlt SflaquoJiholm S11Jttlm bullDeptfrtmfmfrfpydd4try Utriwr5ifyoPermsylwnfR PhilRdelphilf PA USA DcpatmentafSrmisticB WeslChesmUnlr1ersily WfstChestaPldWelpIdll PA USA

Introduction This atady examined wbether meuures of PenonMtty Disorder (PO) from the Dlapoadc and S~Manual of MenJBl Di80tder IV psydlodynamk character psydWoslail mindednas lnterperaonal pattun and penonallly trafta predidH tlUtDumt oubome for PO patients Method ConIecutive 1D patient were nn-shydomly assIped to manua1lzed tlme-lIadted $Upporti~lve PfYChotherapy (SSP 11-76) or lotI~d opetHnded commu- alty delivered payehodynamk tredDl_t (CUPT II - 80)bull SIpJfkallt pred1donwere tested toptherhl orderfo exammewbether they modshyeratM or predided the reductiOD 01 psyddatrlc IJYIIlPfOUI (Symptom Check Liart-9O)1lesults Inthe~patientswith IDOntBeVete

alpiBcanfIyrelaled to bipet tate-of improvement In the CDPTtieatshym_tcompued with SEP CondVlon Due to the faCtthat more severe PO patients had lower rates of im~imtIo~ ltutment=

amp iiiidiip1 ampIi POPUlAO- Sp5~= jiiOplmimpKt whether patientliOUld reeeift tnanuaUzed or non-manualmiddot ~ttoPYfllit0 2001 John Wiley III Sone m

INTRODUCTION Demands for time-limited and manuaBzed evimiddot d~psychotherapy (BBP) areincreasing as

tCtmepmdence CO Do VImars Deparimrnt of Paych1atry a means to use Hmibd leIIOl1Ite6 more effedively Payldatii8ka DlCttCentnanluaMt Iitlfavlp 3-9 lC5 ~ and to increase the UkelIhood that patien1s will NOr$botamp Swaden receive reasonable and effective treatment ~ B-maDbo~ Novotny Ie ThoinpsonmiddotBrenner 2(04) BBP guideshyPart of the artlde WM ~kd at Itie annual ~ of the linea usually target spedflc relatively hamogeshySociety for PaychoIberapy ~h (SPR) In Senta 8Grbam CAt USA In im DeoUS axis 1 psychiatric DIagn~ and Statfstical

- fIWlllYCopyright 2001 Jo1m Wiley at Sons Ltd iamp InferSciel1Cemiddot ne uu fU

levels ofPD di8cml~ 6iuUlbei~ve FD crd ba~ ssectshywith bull ofiDterDe1sOna1 PrOblems

evel8 Of IJP dOmilWlCfJ were

_ J-IIltenlive Short-term DYnamic Psyehotbenpy for DSM IV PmouJity Diso~en

A Randomized ControDed Trial MM-J IrFlyengt d J (til 1 Abstract tw~frWJ~ Thi8 study eya1uated the efficaCy and long-term effectiveness of Intensive ShorHerm ~c

Psychotherapy (ISTDP) in the treatment o~patients with DSM IV personalitYdisorders (PD)

Twenty-seven patients with PD were ~mized to treatment with ISTDP or a minjmal-contact

de1ayed-llea1ment control condition ISIDP treated patients improved significantly more than J

controls on all primary outcome indices reaching the nmmal ranges on both the Brief Symptom- ol

Inventory (151 to 051 pltOOI) and ~nventory of Interpersonal ~blems (156 to O67PltOOI)----

When control patients were wated they experienced benefits similar to the initial1reatment

group In long-term fonow-up the whole grouP maintained their gains tUlLLhad an 833

reduction ofpersonality disorder diagnoses Treatment co~ were tluice offset by reductions in

medication anddisability middotp8ymeirts This preliminary study ofISIDP suggeSts it is efticaciOWI

and CltSt-effective in the ~t afPD Limitations ofthis study and suggestions (or futuremiddot

research are disCussed

Key Words Psychotherapy short-tenn personality disorder psychodynamic


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27

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121

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113

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27

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121

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113

226







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Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







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Psychodynamicshy

27

13

A B and C

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as 12

24

12

178

121

139

113

226







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WHATS TO TALK ABOUT


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Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







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-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







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~ -~ shy ~

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Tore C Stiles PhD


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-----~---























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Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


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-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












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I

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Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

~ lIICiWI ~

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IIRIM 11

at 0


~ ttIpisII pII-


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~~~ ---------------~ ~~~~-----


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98

















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9 __~1IIlIlllCllO~




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~












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lt bull

A a H()JfJ(Uh
















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911-(01 (n ~~ 1IopIW

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-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











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-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




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Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







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637

~~~ ---------------~ ~~~~-----


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lt bull

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911-(01 (n ~~ 1IopIW

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-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











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-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







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IIRIM 11

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637

~~~ ---------------~ ~~~~-----


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98

















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Tore C Stiles PhD


(
















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A a H()JfJ(Uh
















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911-(01 (n ~~ 1IopIW

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Introdudion





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-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













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IIRIM 11

at 0


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II

















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637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















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Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w



























911-(01 (n ~~ 1IopIW

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~ ~o a JI t shyi

t ~ amp fIi ft shy

~









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-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

~ lIICiWI ~

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IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

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v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













pound81


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liI5UL-~~




































Introdudion





~--1I ~1 Jlif

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~ ~o a JI t shyi

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~









process research



-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













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IIRIM 11

at 0


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II

















bd


- p II lup2l- (It)

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v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













































Introdudion





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fIi If

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if



If ~H~middot - iH



[~

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t ~ amp fIi ft shy

~









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-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













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at 0


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MIl



II

















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v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













~--1I ~1 Jlif

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if



If ~H~middot - iH



[~

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~ ~o a JI t shyi

t ~ amp fIi ft shy

~









process research



-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

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IIRIM 11

at 0


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MIl



II

















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v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w





















process research



-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







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IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















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v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













-_REVIEW






-----~---























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

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IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

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v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w


























PH BOm7S58(90)OOO5



Falk Leichsenring

Uni~ty ofGlJttingen




~ crittt1ia 7IIfIll


I


40J

I











i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

~ lIICiWI ~

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IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

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v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w























i psychotherapy


















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

~ lIICiWI ~

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IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

~ - p ~


pound3 _-

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~ -- l1li shy~



- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w






















-












85 I


WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

~ lIICiWI ~

- tI

IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

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- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w














WHATS TO TALK ABOUT


WHAT REALLY GOES ON




2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

~ lIICiWI ~

- tI

IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

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- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













2



GOING FIRST CLASS




l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

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IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

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- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













l












I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

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IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

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- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w




















I - I-- bull shy

I

~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

~ lIICiWI ~

- tI

IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

~ - p ~


pound3 _-

~ ampdiu~IIDIUP



~ -- l1li shy~



- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













~




Ei to 2


Hardy et al


Psychodynamicshy

27

13

A B and C

C

as 12

24

12

178

121

139

113

226







(1994) 1980) Mean (SD) 307 (10) 189 (73) 091 (05) 097 (05) 147 (1







~Itduatp I













~ -~ shy ~

~ lIICiWI ~

- tI

IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

~ - p ~


pound3 _-

~ ampdiu~IIDIUP



~ -- l1li shy~



- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w


















~Itduatp I













~ -~ shy ~

~ lIICiWI ~

- tI

IIRIM 11

at 0


~ ttIpisII pII-


MIl



II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

~ - p ~


pound3 _-

~ ampdiu~IIDIUP



~ -- l1li shy~



- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













II

















bd


- p II lup2l- (It)

1 _

4DIIf ~PII (p)

~ - p ~


pound3 _-

~ ampdiu~IIDIUP



~ -- l1li shy~



- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













- - v





















v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













v IJnef~~ ~















532











PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w















PSYCHOTHERAPY














637

~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













~~~ ---------------~ ~~~~-----


Jonathan Shedler







98

















f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w













f


Article




Tore C Stiles PhD


(
















~J~~ 11t1fUJ1J























II( w






























II( w













Evidence Base for Psychodynamic Psychotherapy

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Transcript of Evidence Base for Psychodynamic Psychotherapy