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Analysing the effectiveness of long-term therapy

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I’ve just caught up with a 2008 article in the Journal of the American Medical Association reviewing a meta-analysis of studies looking at the effectiveness of long-term psychodynamic psychotherapy. The meta-analysis looked at 23 studies, including 11 randomised controlled trials and involving 1,053 patients. The meta-analysis concluded that long-term psychodynamic psychotherapy led to significantly better outcomes than shorter forms of psychotherapy, especially for individuals who were experiencing more complex mental disorders. Thanks to Mike Langlois who pointed out this article to me.

The meta-analysis looked at studies, published over the past 50 years, of individual psychodynamic psychotherapies that lasted for at least one year. Studies were only included if they had reliable outcome data and had a prospective design, that is, they included before and after assessments of the patient. Patients treated in the studies had a range of mental disorders including ‘personality disorders, chronic mental disorders (defined as mental disorders lasting ≥1 year), multiple mental disorders (defined as 2 or more diagnoses of mental disorders), and complex depressive or anxiety disorders’.

The two authors independently rated the reported treatment outcomes in terms of overall effectiveness, the presenting problems, general psychiatric symptoms, personality functioning and social functioning. The studies were then analysed to compare the outcomes achieved by long-term psychodynamic psychotherapy, with those of other forms of therapy, including ‘CBT, cognitive-analytic therapy, dialectical-behavioral therapy, family therapy, supportive therapy, short-term psychodynamic therapy, and psychiatric treatment’.

The article describes the detailed statistical analysis that was carried out on these 23 studies. This analysis came to the following conclusion:

In this meta-analysis, (long-term psychodynamic psychotherapy) was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning. Long-term psychodynamic psychotherapy yielded large and stable effect sizes in the treatment of patients with personality disorders, multiple mental disorders, and chronic mental disorders. The effect sizes for overall outcome increased significantly between end of therapy and follow-up.

Interestingly, the number of therapy sessions seemed more significant in these positive outcomes, than the number of weeks that the therapy lasted.

There are growing pressures, at least within the UK, for psychotherapy to be offered in its shorter, and therefore less costly forms. It’s certainly correct for a range of help to be available to people in distress. It is also true that many individuals may only need, or be prepared to contemplate, a relatively brief therapy. However, the studies looked at in this analysis suggest that more complex or chronic problems are best helped by longer-term work.

As a society and as individuals we face difficult economic realities. In both cases we need to decide how much we want to invest in our mental wellbeing.

The effectiveness of brief interventions in A&E

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A recent study suggests that brief alcohol interventions in A&E may not be as effective as other studies have indicated. However, within this overall disappointing result, variations in counsellor skills may have a positive effect upon outcomes.

The Swiss research, reported in Findings, used a sample of 987 heavy drinkers to explore the effectiveness of brief motivational interventions in A&E. The disappointing headline result was that in this study, at least, receiving a brief intervention did not seem to lead to any greater level of improved outcomes in drinking one year later. About two-thirds of the participants were still drinking heavily after one year, regardless of whether or not they had received a brief intervention. This does contradict other studies, which have shown some positive effects from this form of intervention. For example, another study mentioned in Findings found that brief motivational interventions did seem to lead to a reduction in harmful drinking for dependent drinkers who were admitted to A&E with an injury.

However, the Swiss researchers also looked in more detail at these brief interventions and at the performance of individual counsellors. They found that although the overall results were disappointing, some patient and counsellor characteristics did predict a more positive outcome. The analysis was based upon a sample of only five counsellors and so should be treated with great caution. What it did find was that counsellors tended to produce more positive results to the degree that they delivered the interventions in a motivational style. The article describes this style in terms of demonstrating acceptance of the patient, having a collaborative approach and emphasising the individual’s control over their behaviour.

People who are approached with a brief alcohol intervention in A&E are generally there for some other reason and are not expecting an intervention regarding their alcohol use. The background notes to the article in Findings suggest that in this case, especially, a collaborative and non-confrontational approach is more likely to be successful.

Psychotherapy and the trustworthiness of randomised controlled trials

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One of the criticisms levelled at psychoanalytic psychotherapy is the absence of evidence for its effectiveness and, especially, the absence of randomised controlled trials (RCTs). By comparing outcomes for randomly selected groups of individuals who receive different treatments or none, these trials set out to prove the effectiveness or not of treatments. RCT is often described as the gold standard of research. In the past, psychoanalytic psychotherapists have been reluctant generally to undertake research and especially research that uses RCTs. This attitude towards research seems to be changing with an increasing number of research studies that demonstrate the effectiveness of psychoanalytic psychotherapy. See, for example, my blog post ‘Psychodynamic psychotherapy brings lasting benefits through self-knowledge’ – http://goo.gl/40fiy.

More research into the efficacy of psychoanalytic psychotherapy is certainly desirable and as practitioners we should be self-critical enough to welcome external validation of our methods. However, it’s worth also being aware that much medical research, including RCTs, is less scientifically sound than is often thought.

A recent article in the Atlantic describes the work of John Ioannidis and his team at the University of Ioannina. See http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269/

The team is investigating the credibility of published biomedical research, including looking at studies that were originally thought to be conclusive, but have later proved to be incorrect. In one of their papers they looked at 49 of the most highly regarded and frequently cited medical papers published in the last 13 years. Of these papers, 45 contained claims for effective interventions, but only 34 of these had been retested, leaving 11 without independent verification. Of those studies that were retested, 14 or 41% ‘had been convincingly shown to be wrong or significantly exaggerated’. So two fifths of these key papers, when retested, were shown to be misleading, papers that were widely cited and referred to by physicians for guidance.

Also worrying was the persistent influence of these misleading studies. The article mentions ‘three prominent health studies from the 1980s and 1990s that were each later soundly refuted…(where) researchers continued to cite the original results as correct more often than as flawed—in one case for at least 12 years after the results were discredited’.

The Atlantic article describes several factors that Ioannidis claims can distort research outcomes and influence the likelihood of publication. These include the pressures of competition for funding and academic success, and plain wish fulfilment on the part of the researchers.

Research into all forms of therapy is to be welcomed. However, the efficacy of some approaches is more easily investigated with RCTs and these forms of therapy are often held up as having a more secure evidence base. These are claims that should be challenged. The work of Ioannidis and his team shows that RCTs do not necessarily provide a trustworthy and scientific proof of efficacy.

Schizophrenia and ‘The Insanity Virus’

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A recent article in Discover links the development of schizophrenia with a human endogenous retrovirus, HERV-W. The article follows the work of E. Fuller Torrey and others in exploring a viral basis for schizophrenia.

Endogenous retroviruses are the remains of viral infections that occurred in past generations and that became encoded within the genome. In the case of HERV-W, this encoding may have taken place millions of years ago in an early primate ancestor. The HERV-W is one of several ancient viruses that have left their imprint upon the human genome.

It is currently believed that in most cases these viral remnants in our DNA are not expressed and have no effect upon humans. There is some evidence, though, that HERV-W may play a role in the development of both multiple sclerosis and schizophrenia. The suggested pathway involves early infections that trigger the virus, leading to an immune reaction that damages our nervous system and that can eventually cause either of these conditions. Later infections may also play a role.

This is a line of research that could offer future ways of helping to prevent or to treat schizophrenia. As such it is an important endeavour. However, it is a common error to argue for a single cause for a complex, multi-factorial process. The Discover article falls into that trap, as shown by its title: ‘The Insanity Virus’. Even if the theories of Torrey and others prove to be correct, what they give us is a description of one factor in the development of schizophrenia. Other factors, including the individual’s environment, are also likely to play a role. The suggested pathway involves the human immune system, which has been shown to be heavily influenced by psychological factors such as stress. For that reason our early emotional life may play a crucial role in the development of schizophrenia, even within the causal model proposed by Torrey.

Torrey and other writers looking for a purely biological explanation for mental disorders discount the importance of the infant’s early experience of their world. This ignores the intimate ways in which our mind and body interact and effect each other’s development. It is an approach to human beings that is as one sided as the purely psychological. It is also a view that ignores the healing potential of therapeutic relationships.

Parenting rewires fathers’ brains

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It seems that very specific structural changes take place in the brains of fathers and their young children when they interact with each other.

A recent article in Scientific American – The Brains of Our Fathers: Does Parenting Rewire Dads? – describes research on mice and rats that shows how close interactions between fathers and newborns produces significant neurological changes in both individuals. New neurons and neural connections are created when the fathers care for and play with their offspring. These new structures encode the relationship and help to give the bonding permanence.

All of our thoughts, including our perceptions and memories, both conscious and unconscious, are the result of activity in our brain cells and their billions of connections. We form new cells and new connections to encode new thoughts and memories, making those experiences available to us at a later time. The researchers found these changes took place in certain areas of the brains of rat fathers and offspring, but only if the pair were allowed contact with each other. Degu rats were used in this research because Degu fathers usually play an active role in the early care of their pups.

It would be less surprising if the brains of mother rats and their offspring underwent similar changes. Mothers and pups experience the intimate relationships of gestation and lactation, with their associated hormonal changes. What is interesting about the reported studies, is that these neural changes also take place in the brains of father rats and their offspring. The studies provide further examples of the intimate and ongoing ways in which the external world shapes the structure of our brains.

However, the article then goes on in a way that I think is less helpful. The latter part of the article speculatively links absent human fathers, neurological deficits and later behavioural problems in the offspring. This linkage has prompted a lively debate on the Scientific American website about the effects of absent human fathers and the relative importance of biological and social factors in developing problems such as delinquency and addiction.

To me it is a dangerous oversimplification to extrapolate from these Degu rat studies to say that the absence of a human father necessarily leads to neurological deficits, which in turn will lead to delinquency. Both stages of that argument are open to serious challenge.

For example, the neurological deficits seen in these studies may not have been the direct result of the absence of a father rat. Instead they could have been caused indirectly by the extra strain placed upon the mother by not having a partner to share in parenting duties. However, support for human mothers can come from a range of sources other than a father, for example, from a non-father partner or from an extended network of family or friends.

The article drastically simplifies any possible causal links between early neurological deficits and later delinquency. Many biological, psychological and social factors affect our journey from birth through to adulthood. The danger of this article is to imply a form of biological determinism; that the absence of a father tends to create an early and long-lasting, neurological abnormality that contributes to later delinquency.

Concrete plans in brief interventions for heavy drinkers

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A recent study showed that very brief interventions with heavy drinkers were far more effective when the participants were asked to choose or to make concrete plans for alcohol reduction.

The British study was carried out in public places, such as shopping centres, where 471 people were asked to take part in a survey about alcohol. Around half agreed and were then given a questionnaire to fill in that contained information about safe drinking levels. The participants were randomly given one of four versions of the questionnaire, three of which had a different instruction at the end. The three instructions to participants were either:

  1. A request to write down a plan for reduced consumption.
  2. A choice between one of three pre-set reduction plans based upon an if-then model.
  3. An instruction to formulate their own if-then plan.

(An if-then plan makes an intention for future behaviour change more concrete by putting it into the format of ‘if this happens, then I will do/not do this‘.)

Around a third of the respondents were exceeding recommended safe drinking levels.

Follow up surveys a month later showed no changes to the drinking levels of the two-thirds of respondents who were not exceeding safe drinking levels. However, amongst the heavier drinkers there was a marked difference between those given the questionnaire with no instructions, who reported almost no change, and those given questionnaires with one of the three instructions listed above. Those given instructions tended to reduce their alcohol consumption, with the more concrete if-then plans prompting a significantly greater change.

The period before follow-up was fairly short and the effects of these interventions may not be long lasting. However, the study suggests that even a very brief, self-administered intervention can have an impact upon heavy drinking, particularly if the intervention includes support in making a simple, concrete plan for behaviour change. Asking participants to choose or to make an if-then plan may help to fix an intention and to rehearse its implementation.

A report and discussion on the study can be found here.

Morality and empathy in babies

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Recent research is throwing more light on the moral understanding that young infants have of the world. Paul Bloom, a professor of psychology at Yale, has written a New York Times article about research at the Infant Cognition Center into the moral life of babies. As well as showing how even very young infants start to develop an understanding of how the world functions, the research also demonstrates the early existence of empathy and identification.

Bloom’s article begins by describing the baby’s early understanding of physics and psychology, and the techniques used to investigate this understanding. Rather than living in a completely chaotic world, eye tracking techniques show that even very young babies have realistic expectations about such things as the operation of gravity and the movement of objects through space and time. For example, babies show surprise when objects appear not to conform to these laws. While their expectation of the external world may be relatively naive, these babies nonetheless show an early understanding of how the world is structured.

As well as this understanding of the external physical world, toddlers also show some early understanding of the existence of internal world within others. Bloom quotes a study which shows that 15 month-old toddlers are able to conceive of the mental life of other people. The toddlers are shown an adult watching an object being placed inside a box. The object is then removed from the box without the adult’s knowledge. However, the infants still expect the adult to look for the object in the now empty box. For this to be the case the toddlers must understand how the adult mistakenly views the world, the infant must have an idea of the adult’s internal world.

The researchers at the Infant Cognition Centre have gone on to use these techniques to explore what moral understanding babies have of the world. Their investigations involve showing babies puppets or geometrical shapes as characters in situations in which they helped or hindered someone else. Babies who were as young as 5 months old showed a preference for the helpful shapes or puppets over the unhelpful ones. To get closer to ideas of justice, the investigators then introduced situations of reward or punishment. Helpful characters were rewarded or punished by another puppet, and unhelpful characters were treated likewise. When the character was helpful, the babies preferred the puppet that was rewarding it rather than the puppet which punished. However, with the hindering characters the preference was reversed, with the babies preferring the puppet who punished the character. The babies demonstrated a sense of fairness.

In Bloom’s discussion he argues that these experiments show the early existence of a naive moral understanding held by infants, similar to their naive understanding of the physical and psychological worlds. At an early stage we have the tools with which to judge the actions of others and to respond to kindness and meanness. However, Bloom points out that this understanding is still very undeveloped and unmodified by culture and rationality.

These are interesting findings which show the infant’s early understanding of the world, including the internal worlds of other people. The findings join a growing body of evidence for our early capacity for empathy and identification. In their preferences for ‘nice’ characters it is likely that these babies were identifying with the characters in these vignettes. As well as understanding the internal worlds of others, these babies were internalising the external world, becoming involved in these dramas and making judgements about the participants. These are processes which lie at the heart of a psychoanalytic understanding of human development.

Is abstinence from alcohol the only reasonable treatment goal?

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Further analysis of data from the UK Alcohol Treatment Trial (UKATT) throws more light on the debate about abstinence or non-abstinence as a treatment goal for people seeking help with an alcohol problem. [1] (Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes. Alcohol and Alcoholism 2010 45(2):136-142.) The analysis compared treatment outcomes for individuals who at intake were aiming at abstinence with those who were not. Outcomes were compared after three months and at a twelve-month follow-up. Read more Is abstinence from alcohol the only reasonable treatment goal? ›

Addiction and psychotherapy 1 – Introduction

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This is the first in a series of posts about addiction and psychotherapy. The posts are aimed at general readers who want a better understanding of addiction, including people who are concerned about their own possible addiction or about someone else.

My ideas are based upon the experience of working in the field of addictions for over thirty years. This is a field in which various different points of view are strongly held and often strongly contested. There is no consensus about how addictions are caused or how best to treat them. My belief is that there is no single model of addiction that can explain the unique and varied experiences of all the individuals who struggle with this issue. What I present here are some ideas that make sense to me and that have helped people I have worked with. I recognise that there are other approaches that people have also found useful.

There are many behaviours that can become addictive – including using alcohol or drugs, gambling or having sex, to list a few. What these addictions have in common is a compulsion to keep on repeating something beyond the point at which it starts to do us harm. The question is: why do we carry on with behaviours that are risky, taking them to a stage where they are hurting us, and then carrying on some more? In these posts I shall look at some ways to understand this behaviour and, in later posts, look at some treatment issues. Read more Addiction and psychotherapy 1 – Introduction ›