This paper was published in 2005 in Psychology and Psychotherapy

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  • 1. Personality pathology, adaptive functioning 1Running Head: PERSONALITY PATHOLOGY AND PSYCHOANALYSIS Clinician reports of personality pathology of patients beginning and patients ending psychoanalysis Rosemary Cogan Texas Tech University and John H. Porcerelli Wayne State University School of Medicine This paper was published in 2005 in Psychology and Psychotherapy: Theory, Research and Practice, 78, 235-248.
  • 2. Personality pathology, adaptive functioning 2 AbstractObjectives The purpose of this work was to use a clinician Q-sort procedure to describe thepersonality pathology and adaptive functioning of patients beginning and ending psychoanalysis.Design With a cross sectional design, we compared a group of patients beginning and a group ofpatients ending psychoanalysis.Methods Twenty-six psychoanalysts described a patient beginning psychoanalysis and 26described a patient ending psychoanalysis using the Shedler-Westen Assessment Procedure 200(SWAP-200). Each clinician also completed questions about themselves, the patient, and thetreatment. The most characteristic SWAP-200 items describing patients beginning and patientsending psychoanalysis provide a meaningful picture of the two groups.Results Among patients at the end of psychoanalysis, scores were significantly lower on theSWAP-200 Paranoid, Schizotypal, Borderline, Histrionic, and Dependent scales and scores weresignificantly higher on the SWAP-200 High Functioning scale and the DSM-IV GAF scale.Common characteristics of patients beginning psychoanalysis were anxiety, guilt, and shame.Common characteristics of patients ending psychoanalysis were conscientiousness andresponsibility, striving to live up to moral and ethical standards, and enjoyment of challenges.Conclusions The findings demonstrate the usefulness of a clinician report measure for the study ofpsychoanalytic psychotherapy and psychoanalysis.
  • 3. Personality pathology, adaptive functioning 3 Introduction Our goal is to assess the viability of using a clinician-report methodology to studychanges in personality pathology in long-term psychotherapeutic treatments as they are carriedout in the community. The present work is a descriptive cross-sectional study of a group ofpatients at the beginning of psychoanalysis and a different group of patients at the end ofpsychoanalysis. If this method is sensitive to differences between these two groups, then themethod can be used later in a longitudinal study, following change in a group of patients over thecourse of long treatments such as psychoanalysis or psychoanalytic psychotherapy. Although there are several clinically relevant self-report (e.g., MMPI-2, Hathaway &McKinley, 1989) and interview (e.g., SCID-II, First, Spitzer, Gibbon, Williams, & Benjamin,1996) measures of personality pathology, these measures are less than ideal for studyingpersonality pathology in everyday clinical practice in the community. A reliable, valid, andstandardized clinician-report measure has several potential advantages. Clinicians aresophisticated observers of behavior (Shedler & Westen, 1998), who consider patients explicitreports about their symptoms, histories, and relationships, and also consider patterns of relatingthat occur between therapist and patient within the consulting room. Although clinicians can anddo have biases, multiple contacts with patients and the use of psychometrically soundinstruments can provide a comprehensive description of personality characteristics and disorders.A clinician-report measure also does not raise the formidable problems of obtaining confidentialpatient information from clinicians practicing in the community, since clinicians can describetheir patients anonymously. Studies of the outcome of psychoanalysis have been reported since 1917 (Coriat).However, the majority of studies of the outcome of psychoanalysis and psychoanalytic
  • 4. Personality pathology, adaptive functioning 4psychotherapy have had methodological problems, and questions remain about the effectivenessof these treatments. Roth and Fonagy (1996) have noted that the relative absence of evidence forpsychodynamic therapies is sometimes misunderstood as an absence of the efficacy of thesetherapies. There have been several relatively recent large-scale effectiveness studies ofpsychoanalysis. A major outcome study was The Menninger Foundation PsychotherapyResearch Project (Kernberg, Burstein, Coyne, Applebaum, & Horowitz, 1972; Wallerstein,1986), a prospective longitudinal study of psychoanalytic outcome. The Menninger projectcompared patients in psychoanalysis and psychoanalytic psychotherapy, with follow-ups two tothree years after the end of treatment. Patients in the Menninger project were more disturbedthan most patients entering psychoanalysis. Half of the patients in psychoanalysis had borderlinefunctioning, 35% had problems with drugs and/or alcohol, and 33% had paranoid features. Onthe Health Sickness Rating Scale (HSRS; Luborsky et al., 1993), a precursor to the DSM GlobalAssessment of Functioning (GAF) scale (American Psychiatric Association, 1994), patientsbegan with average ratings of 45.6. Like the GAF, the HSRS ranges from 0 to 100 and theaverage initial rating of 45.6 indicate serious impairment in functioning. Among 22 patients inpsychoanalysis and 20 in psychoanalytic psychotherapy, the average HSRS scores increased withtreatment. At two-year follow-up, HSRS scores were 61.7, indicating some mild symptoms.Although the assessment of patients before and after treatment was sophisticated and complex,the Menninger study was carried out before the adoption of standardized criteria for personalitydisorders. Since the Menninger study, several studies of psychoanalytic outcome have beenreported. Bachrach, Galatzer-Levy, Skolnikoff, and Waldron (1991) summarized the results of
  • 5. Personality pathology, adaptive functioning 5six studies of terminated analyses involving 550 patients and concluded that 60-90% of patientsselected as being suitable for psychoanalysis showed substantial therapeutic benefit as evaluatedby the treating analysts. Doidge, et al. (2002) reported on the survey responses of 510psychoanalysts in the U.S., Canada, and Australia who described the psychopathology andtrauma histories of 1,718 patients in psychoanalysis. These patients had substantialpsychopathology and histories of trauma. Before beginning psychoanalysis, 82% of the patientshad tried other treatments or medications. At the beginning of psychoanalysis, 71% had one ormore DSM-III-R Axis II disorders. These data indicate that the patients began psychoanalysiswith significant psychopathology. The results of the survey showed that psychoanalysis lastedan average of five to six years and that more patients were employed as psychoanalysisprogressed. No data were reported as to changes in psychopathology as a function of treatment. In Germany, Leuzinger-Bohleber (2002) reported on a six-year effectiveness follow-up ofthe outcome of psychoanalysis among 401 patients. Half were followed-up with questionnairemeasures and half with interviews by an independent analyst, audio tape-recorded, and reviewedby a research team. The research team found that patients were more satisfied with the treatmentoutcomes than psychoanalysts, who were more cautious in estimating therapy outcomes. Keller,Westhoff, Dilg, Rohner, and Studt (2002) reported on the outcomes of psychoanalysis among111 patients who had completed at least 100 sessions of psychoanalysis. The severity ofsymptoms reported by patients on the Symptom Check List-90 (Derogatis, Lipman, Rickels,Uhlenhuth, & Covi, 1974), a self-report measure of psychiatric symptoms, was reduced afterpsychoanalysis. Significant reductions in symptoms reported on the SCL-90 afterpsychoanalysis have also been reported by Sandell et al. (2000) in a longitudinal study whichinvolved several hundred patients in Stockholm before, during, and after psychoanalysis or
  • 6. Personality pathology, adaptive functioning 6psychotherapy. Significant reductions in work absenteeism and in health care costs afterpsychoanalysis or long term psychoanalytic psychotherapy have been reported recently byBeutel, Rasting, Stuhr, Ruger, and Leuzinger-Bohleber (2004). More than 80 completed and on-going studies of psychoanalytic outcome are summarized in Fonagy, et al. (2002). Psychoanalysis has always concerned itself with personality change, also referred to asstructural change. However, standardized measures of personality disorders have not beenincluded as outcome measures in studies of psychoanalysis. Shedler and Westen (Shedler &Westen, 1998; Westen and Shedler, 1999a, 1999b) have recently developed a clinically sensitive,reliable, and valid measure of personality disorders, traits, and strengths which