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The effectiveness of psychodynamic psychotherapy

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A team from the Justus-Liebig University Giessen in Germany has conducted a systematic search for evidence for the effectiveness of psychodynamic psychotherapy. They concluded that this form of therapy was effective for a range of common mental disorders including major depressive disorder, social anxiety disorder, some personality disorders, somatoform pain disorder and anorexia nervosa. They also found some evidence for effectiveness in treating dysthymia, complicated grief, panic disorder, generalized anxiety disorder and substance abuse/dependence. Read more The effectiveness of psychodynamic psychotherapy ›

Talking therapy changes the brain

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Researchers from Massachusetts General Hospital (MGH) have identified changes in the metabolic activity of a key brain region in patients successfully treated for depression with psychodynamic psychotherapy – talking therapy.

The study involved 16 patients with major depression who were offered weekly psychodynamic psychotherapy sessions. Each of the participants had unsuccessfully tried treatment for their depression with medication. Nine of the patients completed the course of psychotherapy and ‘almost all’ reported a greater than 50% reduction in their depression. Read more Talking therapy changes the brain ›

Record of an online analysis

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Interesting description by Carole Rosen of an analysis that she conducted online using Skype. The analysis was conducted in Chinese with a patient in China, while Rosen was, I assume, located in New York and is not a native speaker of Chinese.

Rosen’s description of the clinical material is engaging and moving, but I was particularly interested in two aspects of her paper.

The first was the careful way in which she thought about the cultural framework of her Chinese patient. She describes both some general aspects of Chinese culture and also some specific issues faced by the generation that grew up during the Cultural Revolution. This understanding of her patient’s cultural and historical context was important in making sense of her patient’s inner world and in giving him the experience of being held in mind. It was also interesting to see how familiar themes, such as Oedipal relationships, were expressed within this cultural framework.

The second aspect of the paper that interested me was its description of communication across languages and across continents. Rosen was wary both of conducting the analysis in Chinese and of carrying it out over Skype. In both cases she seems to have established a good way of working with her patient, checking with him the meaning of unclear words and his preferred way of working at distance. She’s alert to the ways in which these issues are present within the transference and in themselves can provide useful avenues through which her patient’s phantasies can be explored.

Although I work solely in English, I’ve worked with many people who have English as a second language or who come from a very different culture to mine. In this work it’s been important to check our shared understanding of words. Even when working with someone whose first language is English, we can’t assume that we both mean the same thing by the same word. Being aware of and exploring different meanings is part of developing a shared understanding of each other and of building our relationship.

I’ve also worked via Skype and I agree that a therapeutic relationship can be developed in that way. It’s not the same as being in the room together, but a relationship can be built and change helped along.

via the website International Psychoanalysis

Psychoanalysis and research

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An editorial piece for the December 2010 edition of the journal Psychoanalytic Psychotherapy makes for challenging reading. The authors strenuously criticise the indifference and resistance towards research that they see amongst many psychoanalysts.

Given the time, cost, and intensity of the demands placed on patients and therapists who enter into psychoanalysis, the fact that the field has neglected to perform appropriate assessments of whether or not the treatments we routinely recommend and deliver actually work is shocking.

The authors are not anti-psychoanalysis, both are staff members of the Columbia University Center for Psychoanalytic Training and Research. Part of their concern is for the diminishing prevalence and influence of psychoanalytic treatment, which they relate to the absence of sound evidence for its effectiveness. They dismiss those forms of evidence that are most often used by psychoanalysts and psychodynamic psychotherapists.

…clinical lore, collegial interaction, and direct observations by sole practitioners can appear superficially rational as a basis for determining the effectiveness of a treatment….
Psychoanalysts pride themselves on their awareness of the impact of fantasy and wishful thinking during their treatments, but minimize the impact of such factors on their subjective assessment of their own clinical outcomes.

In place of such subjectivity, the effectiveness of these treatments should be evaluated using randomised controlled trials based upon treatment manuals, so that the practitioner’s adherence to the treatment protocol can be assessed. Although some effectiveness studies have been published, it is claimed that many are flawed.

As I say, a challenging article, and one that leaves me with contradictory thoughts.

On the one hand I do feel the lack of a widely-accepted evidence base for the effectiveness of psychoanalytic psychotherapy. I do think that such a body of evidence is growing and I appreciate those studies that I see that add to this evidence.

However, I’m uneasy about the the insistence that randomised controlled trials provide the only trustworthy evidence of effectiveness. The work of John Ioannidis, for example, brings the reliability of such trials into question. In a study of 49 of the most highly regarded and frequently cited medical papers published in the last 13 years, his team found that 11 had not received independent verification, while of those that were retested, 14 or 41% ‘had been convincingly shown to be wrong or significantly exaggerated’. 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. (see my earlier post)

I’m also sceptical about the prospect of manualised treatment. For me psychotherapy is about an encounter between two people, with an attempt by the therapist to leave behind preconceptions and to see what use of him or her the patient or client wishes to make. Can a manual allow me to enter into that encounter without memory or desire? Although, I have to admit my ignorance of such manuals and how they are utilised.

And so I’m left with dilemmas that for now I cannot resolve. I want, for myself and for our profession, proof that this practice is effective, both for ethical reasons and to secure our place amongst recommended treatments. But I’m also not sure that the concept of treatment is the best way to describe this journey that I take with my patients. Certainly they come to me in distress and hoping for change. And, given the investment noted above, they deserve to find that our encounter is worthwhile and helps to bring about change. But I have doubts that this is best described in terms of a DSM diagnosis or the relief of a symptom.

Mother-infant psychoanalysis

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A Swedish study, involving mothers with troubled infants, showed improvements in mother’s depression and her relationship with her baby following a two-month course of two or three times a week psychoanalytic treatment for both mother and infant.

I recently came across a link to this interesting study, reported in Science Daily last year. The study followed 80 mothers who had sought help at Child Health Centres, nursing centres or  parenting internet sites. All of the mother-infant pairs received support from the centres, but half were also assigned to joint psychoanalytic treatment at the Mother-Infant Psychoanalytic Project of Stockholm. The treatment lasted about two months, with two to three sessions a week.

The treatment provided a safe environment in which the mother and her baby could  express how they felt. With the help of the analyst the mother could come to understand her baby’s ‘difficult’ behaviour as a form of communication, rather than as an attack upon her or a result of her failure. In this safe place the mother and baby could finally find each other.

In follow-ups six months later, mothers who had received the psychoanalytic treatment showed improvements in their depression, better relationships with their babies and a greater sensitivity to their baby’s signals, as compared to mothers who had only received the support of the Child Health Centres.
See http://www.sciencedaily.com/releases/2010/04/100413072042.htm

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.

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.