More Data Demonstrate Efficacy of Psychotherapy

Three recent studies are providing a much-needed boost to the morale of psychotherapists and psychoanalysts at a time when their field has been under fire for not being able to “prove itself.” These studies provide details on the effectiveness of psychodynamic psychotherapy or psychoanalysis using controlled, randomized, clinical trials with subjects who have specific DSM diagnoses—believed to be a first for the field.

“To be sure,” said Glen O. Gabbard, M.D., the Callaway Distinguished Professor at the Menninger Clinic in Topeka, Kan., and vice chair of APA’s Commission on Psychotherapy by Psychiatrists, “practitioners of psychotherapy have been slow to use rigorous empirical methods to demonstrate the usefulness of what they do. At long last, however, research data have been accumulating that suggest psychotherapy produces lasting improvements and even changes brain functioning. Because the mind is inextricably connected to the brain, these findings should not come as a surprise.”

The significance of the studies is threefold. First, two of the studies involved specific patient populations, one with panic disorder, the other with borderline personality disorder. The studies are among the first to systematically link psychodynamic therapy or psychoanalysis to significant improvements in these groups.

Second, the improvements appear to be not only long lasting, but continued, even after termination of the therapy or analysis.

Last, the third study, undertaken in a large patient population in Sweden, again demonstrated long-lasting and continued improvements due to both psychodynamic psychotherapy and psychoanalysis; however, in this study psychoanalytic techniques were linked to significantly greater improvements than psychotherapy. Also, this study is one of the first to be effectively randomized and controlled in looking at the long-term effectiveness of the two treatments, independent of the patients and the point at which they were in their treatment at the time they were surveyed.

Looking at Specific Diagnoses

A report in the November 2000 American Journal of Psychiatry (AJP) by Barbara Milrod, M.D., and her colleagues detailed an open trial of psychodynamic psychotherapy for panic disorder. Preliminary data suggest that in the study population, statistically significant and clinically meaningful improvements were seen in panic, depression, anxiety, and functional impairment both at treatment termination and at follow-up after six months. The treatment involved a 24-session, twice-weekly course of psychodynamic psychotherapy.

“This report is important because it is one of the first systematic studies of psychodynamic treatment of a specific Axis I disorder,” said Leon Hoffman, M.D., chair of the Committee on Public Information of the American Psychoanalytic Association. “Panic-focused psychodynamic psychotherapy may be a promising treatment for panic disorder patients. A randomized controlled trial would confirm the effectiveness.”

The second study to look at a specific diagnostic population appeared in the January AJP. The report, by Anthony Bateman, M.A., and Peter Fonagy, Ph.D., involved an 18-month follow-up to their prior report on the treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization. Forty-four patients who were involved in the original study were followed every three months for a total of 18 months after completion of the treatment phase.

Patients who completed the program not only maintained their substantial gains at the end of treatment, but also showed a statistically significant continued improvement on outcome measures. Each subject was evaluated on frequency of suicide attempts and acts of self-harm, number and duration of inpatient hospitalizations, service utilization, and self-reported measures of depression, anxiety, general symptom distress, interpersonal functioning, and social adjustment.

Both Gabbard and Hoffman agreed that the significance of this study lies in the continued improvement of the subjects, even after termination of treatment. While previous research has suggested that continued improvement may be possible after termination of the treatment, said Gabbard, the Bateman and Fonagy study provides further evidence.

“It is noteworthy,” Gabbard told Psychiatric News, “that while the investigators employed a rigorous experimental design, including random assignment to either the experimental group or the control group, they stressed that their study was an effectiveness trial rather than an efficacy trial.” Gabbard noted that in recent years a backlash has developed against tightly controlled efficacy trials of psychotherapy in academic settings. Criticisms have included typically high rates of patient exclusion, including the exclusion of patients with complicated comorbidity, which results in patient populations that may differ fundamentally from populations in naturalistic settings, compromising the generalizability of the results from the artificial research setting to the “real” world.

“This contribution by Bateman and Fonagy,” said Gabbard, “is a model of effectiveness research, as ordinary clinical referrals were the subjects of the study, a bare minimum of exclusion criteria were used, and the psychotherapy was conducted in a naturalistic setting.”

Randomized Controlled Trials

The third study, published in last October’s International Journal of Psychoanalysis, was a review of the findings in the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (STOPPP).

Acknowledging that psychoanalysis is currently under heavy attack internationally, Rolf Sandell, M.D., and his colleagues in Sweden looked at more than 400 people before, during, and after subsidized psychoanalysis or long-term psychotherapy.

“There are a number of crucial findings in the STOPPP report,” Gabbard said. “But two critical elements of the results are, first, that the patients in psychoanalysis continued to improve after termination. This observation lends support to the notion that psychoanalytic treatments set a process in motion that the patient continues after the formal termination, suggesting an advantage to extended, in-depth psychotherapy or psychoanalysis over short-term psychotherapy or medication. Second, the improvement was particularly striking on measures of psychiatric symptoms, raising questions about the conventional wisdom that psychoanalytic treatments do not address symptoms in the way that other therapies do.”

The STOPPP report was also notable for its methods of randomization and use of controls. The authors sampled patients on a waiting list for treatment, during treatment, and after treatment on three occasions over three years; the authors called this a “three-wave panel design.” The authors then split the entire sample on the basis of the patients’ positions on a “relative to treatment-time” scale, considering this positioning not to have been self-selected.

“Because the timing of the panel waves was independent of where any of the patients was in his or her treatment process, the authors consider this grouping on the time scale a functional equivalent to randomization,” Hoffman told Psychiatric News.

In support of their conclusion, he added, the authors looked at more than 50 possibly confounding variables, such as patients’ and therapists’ demographics, patients’ psychiatric state and history, therapists’ experience, training, and orientation—the authors did not find a single variable that differed systematically between the groups on the time scale.

Mind Can’t Be Bypassed

The significance of the new findings partly remains to be seen, said Gabbard. Nonetheless, the results did not necessarily surprise him.

“I have long thought,” Gabbard wrote in an editorial accompanying the Bateman and Fonagy study in AJP, “that in training psychiatrists, we make too much of a distinction between psychotherapy and pharmacotherapy. The doctor-patient relationship is inherently psychotherapeutic. Even when we treat the brain with somatic treatments, we cannot bypass the mind.”

The AJP studies may be accessed on the Web at www.psychiatryonline.org by clicking on AJP and searching by issue or author name. The STOPPP study is also available online at www.Ijpa.org/sendelloct00.htm. ▪