Analysing the effectiveness of long-term therapy

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

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.