According to the results of the studies presented in this chapter, there is evidence from RCTs that STPP and LTPP are efficacious treatments for the following mental disorders:
Depressive disorders Anxiety disorders Somatoform disorders Eating disorders
Substance-related disorders Borderline personality disorder Cluster C personality disorders
With regard to STPP, the following patient features have a positive impact on treatment outcome (Høglend 1993; Messer 2001; Piper et al. 2001):
High motivation Realistic expectations Circumscribed focus
High quality of object relations Absence of personality disorder
However, these variables seem to have no impact on the outcome of LTPP (Lorentzen and Høglend 2005). According to these results, LTPP seems to be more appropriate for more severely disturbed patients (Lorentzen and Høglend 2005). The same relationship seems to apply to the use of
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transference interpretations: while patients with low quality of object relations do not benefit from a high frequency of transference interpretations in STPP, transference interpretations seem to be useful for these patients in LTPP (Høglend et al. 2006; Piper et al. 1991a, 1991b, 2001).
According to a study reported by Kopta et al. (1994), in which symptom checklists were administered to 854 psychotherapy outpatients at the start of the study and during treatment, about 50% of patients with acute distress were rated as clinically significantly improved after 2 sessions of psychotherapy, 70% after 21 sessions, and 75% after 29 sessions. For patients with chronic distress, the investigators found that 50% of the patients showed clinically significantly improvement after about 11 sessions, and 70% after about 50 sessions. More than 52 sessions were necessary for 75% of these patients to be rated as clinically significantly improved. For patients with characterological distress (i.e., personality disorders), the data of Kopta et al. (1994) suggest that more than 52 sessions are required for about half of the patients to be clinically significantly improved. However, these data do not allow for exact predictions of how many sessions are required for the response rates to surpass the 50% rate.
Perry et al. (1999) estimated the length of treatment necessary for patients with personality disorder to no longer meet the full criteria for a personality disorder (i.e., recovery). Using the available data, they estimated that half of patients with personality disorder would recover by 1.3 years, or 92 sessions, and three-quarters of them would recover by 2.2 years, or about 216
sessions. According to these data, the majority of patients with acute distress benefit significantly from STPP, whereas patients with chronic distress and personality disorders require long-term psychotherapy; such patients do not benefit sufficiently from short-term treatments. In particular, patients with more severe forms of personality disorders seem to need treatment lasting 2 years or longer.
These data are consistent with clinical experience in, for example, the treatment of narcissistic or borderline personality disorder (Gabbard 2005). With regard to depressive disorders, an NIMH study of depression showed that only 24% of patients in the total sample of 239 patients were free of symptoms both 8 weeks after the end of therapy and during the 18-month follow-up period (no major depressive disorder [MDD] according to Research Diagnostic Criteria) (Shea et al. 1992). In this study, no significant differences among CBT, interpersonal therapy, and pharmacotherapy were found (Shea et al. 1992). According to these results, 16–20 sessions of interpersonal therapy or CBT and pharmacotherapy of a comparable duration are insufficient for most patients to achieve lasting remission. Further studies are necessary to assess for which patients short-term
treatments are sufficient and for which patients long-term treatments are required.
Personality disorders have been found to have a negative prognostic impact on depressive disorders (Gunderson et al. 2004; Shea et al. 1990). For example, the rate of MDD remissions seems to be significantly reduced by co-occurring borderline personality disorder (Gunderson et al.
2004). Improvements in borderline personality disorder are often followed by improvements in MDD. For this reason, Gunderson and colleagues recommended that clinicians avoid focusing on the treatment of MDD and hoping that improvements in MDD will be followed by improvements in borderline personality disorder; they should primarily treat the personality disorder (Gunderson et al. 2004).
CONCLUSION
Under the requirements of the criteria proposed by the American Psychological Association Task Force on Promotion and Dissemination of Psychological Procedures and modified by Chambless and Hollon (American Psychological Association 1995; Chambless and Hollon 1998), 31 RCTs are
currently available that provide evidence for the efficacy of psychodynamic psychotherapy in specific mental disorders. In these studies, psychodynamic psychotherapy was either a) more efficacious than placebo therapy, supportive therapy, or treatment as usual, or b) as efficacious as CBT. These results are consistent with the most recent meta-analysis of psychodynamic
psychotherapy, which reported psychodynamic psychotherapy to be superior to TAU or no treatment (in waiting-list control groups) and equally efficacious compared with other
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psychotherapies (Leichsenring et al. 2004). Using the data of this meta-analysis, it can be shown that no differences in efficacy exist if psychodynamic psychotherapy is compared to CBT alone. No significant differences were found between psychodynamic psychotherapy and CBT with regard to target problems, general psychiatric symptoms, and social functions, either at the end of treatment or at follow-up (post: Wilks = 0.88, F = 0.68, P = 0.58; follow-up: Wilks = 0.93, F = 0.18, P = 0.91). This meta-analysis reported large effect sizes for psychodynamic psychotherapy in target problems, general psychiatric problems, and social functioning. These effects were stable at follow-up and tended to increase (Leichsenring et al. 2004).
On the other hand, it is important to remember that there are mental disorders for which no RCTs of psychodynamic psychotherapy have been performed, such as dissociative disorders and some specific forms of personality disorders (e.g., narcissistic). In the absence of data from RCTs, there is clinical experience suggesting that long-term dynamic therapy or analysis may be helpful for histrionic/hysterical personality disorder and narcissistic personality disorder (Gabbard 2004, 2005; Kernberg 1975; Kohut 1971). Clinical wisdom suggests that dynamic therapy is
contraindicated in most cases of antisocial personality disorder, but some data suggest that the presence of depression may increase the likelihood that patients with antisocial personality disorder will respond positively to dynamic therapy (Woody et al. 1985). For patients with PTSD, although one RCT indicated efficacy for STPP, further studies of psychodynamic psychotherapy are needed. For the treatment of children and adolescents, only a few randomized controlled studies currently exist that provide evidence for the efficacy of specific psychodynamic treatments in specific mental disorders (Fonagy and Target 2005). Further studies are urgently required.
Several effectiveness studies reviewed in this chapter have demonstrated that LTPP can yield large pre-post effect sizes and be superior to little or no treatment and to shorter forms of therapy. In these studies, patients with multiple morbidities were treated. Further studies should examine both the efficacy and the effectiveness of LTPP in specific, though comorbid, mental disorders.
Toward this end, an RCT examining the efficacy of LTPP in treating depressive disorders is currently being carried out (Huber et al. 2001).
The results of this review indicate that further research of psychodynamic psychotherapy in specific mental disorders is necessary and should include studies of both the outcome and the active ingredients of psychodynamic psychotherapy in each disorder. Measures more specific to psychodynamic psychotherapy should be applied. In many of the studies reviewed in this chapter, psychodynamic psychotherapy and CBT were equally efficacious. Thus, future studies should address the common and specific factors of psychodynamic psychotherapy, CBT, and other forms of psychotherapy (e.g., interpersonal therapy). They should also examine whether some gains are achieved only by psychodynamic psychotherapy; that is, they should address the question of whether there is "added value" from a treatment with ambitious goals. Furthermore, effectiveness studies should be performed to ascertain how effective various methods of therapy that have proven to work under experimental conditions of RCTs are in actual clinical practice.
KEY POINTS
In evidence-based medicine, randomized controlled trials (RCTs) are regarded as the "gold standard"
for demonstrating that a treatment is efficacious.
The exclusive position of RCTs is increasingly discussed critically.
RCTs are useful to show that a treatment works under controlled experimental conditions.
Naturalistic (effectiveness) studies can provide evidence that a treatment works under the conditions of clinical practice.
RCTs have provided evidence that psychodynamic psychotherapy is efficacious in specific mental disorders.
The methodology of an RCT is difficult to apply to long-term psychodynamic psychotherapy (LTPP) lasting several years. For these long-term treatments, naturalistic studies are more appropriate.
Quasi-experimental designs can be used to improve the internal validity of naturalistic (effectiveness) studies.
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Quasi-experimental studies have provided evidence that LTPP lasting several years is effective.
Process-outcome research has corroborated central assumptions regarding mechanisms of change in psychodynamic therapy.
Further research of both processes and outcomes of psychodynamic psychotherapy is needed.
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