Long-term Dynamic Psychotherapy Research Articles

The Rate of Improvement in Long-Term Dynamic Psychotherapy For Borderline Personality Disorder.

Controlled trials of psychotherapy and follow-up studies of borderline personality disorder (BPD) have shown significant, but usually limited, improvement. We examined the hypothesis that BPD changes more slowly than nonborderline disorders. In a study of long-term dynamic psychotherapy, 16 subjects with BPD and 35 with non-BPD disorders were treated for a median of 3 years with a follow-up of 5 years. From periodic assessments, we calculated the rate of change for each subject over the course of the study on each measure of symptoms and functioning. At intake, borderline psychopathology was associated with higher levels on 76% of 17 measures of comorbid axis I disorders, symptoms, and functioning. BPD psychopathology was associated with faster (not slower) rates of improvement on three measures, but after controlling for the initial level of each measure, there were no significant associations. These findings counsel both optimism and patience in the long-term treatment of patients with BPD.

Comparison of short- and long-term dynamic group psychotherapy: randomised clinical trial

There are no randomised clinical trials comparing the outcomes of short- with long-term psychodynamic group psychotherapy. To compare differences in outcome during and after short- and long-term group psychotherapy. In total, 167 out-patients with mood, anxiety and personality disorders were randomised to short- or long-term group therapy (20 or 80 weekly, 90 min sessions). Outcome measures were: symptoms (Symptom Checklist 90 - Revised), interpersonal problems (Inventory of Interpersonal Problems - Circumplex) and psychosocial functioning (Global Assessment of Functioning (GAF) split version: GAF-Symptom and GAF-Function). Change over the 3-year study period was assessed using linear mixed models. The study was registered in clinicalTrials.gov as NCT00521417. Patients in both groups made significant gains. A significantly larger symptomatic change over time was found for long-term compared with short-term therapy, but no significant differences were detected for the three remaining outcome variables. There was a higher number of premature terminations in the long-term (33.3%) compared with the short-term group (8.6%). Short- and long-term therapy seem equally effective for typical out-patients seeking group psychotherapy, except for symptomatic distress.

Alliance, reactions to treatment, and counter-transference in the process of recovery from suicidal phenomena in long-term dynamic psychotherapy

Objective: We studied therapeutic processes associated with improvement in suicidality in a naturalistic study of long-term dynamic psychotherapy. Methods: In a naturalistic study of long-term dynamic psychotherapy (n = 53), 31 patients reported suicidal ideation, eight of whom also reported prior suicide attempts, while 22 were non-suicidal. Suicide ideation and attempts and components of therapy alliance were followed at 6 month intervals. Results: Suicidal patients had more psychiatric diagnoses, were treated longer and reported more negative reactions to treatment than non-suicidal patients. Alliance moderated (a) the relationship between negative reaction to treatment and improvement in suicidal ideation and (b) the relationship between quality of patient-therapist interaction and improvement. Conclusions: Suicidal patients manifest hostility and negative reactions to treatment, indicating negative transference. Avoiding therapist errors emanating from negative countertransference improves the therapeutic interaction, which is followed by faster rate of improvement in suicidality.

Change in Defense Mechanisms During Long-Term Dynamic Psychotherapy and Five-Year Outcome

Research suggests that defense mechanisms may underlie other aspects of functioning and psychiatric symptoms. The authors examined whether defenses change in accordance with the hierarchy of defense adaptation during long-term dynamic psychotherapy and whether such change is associated with long-term outcomes on other measures. Twenty-one adults with depressive, anxiety, and/or personality disorders entered long-term dynamic psychotherapy (mean=248 weeks) and subsequent follow-along (mean duration, 5.1 years). Measures of functioning and symptoms were gathered in periodic follow-along interviews, external to the therapy. A median of eight psychotherapy sessions over 2.5 years for each participant were rated using the Defense Mechanism Rating Scales quantitative method. Overall, the lowest (action) and highest (high adaptive) defense levels in the hierarchy of defenses improved significantly, as did overall defensive functioning (median effect size=0.71, 95% CI=0.01-1.83). Overall defensive functioning still remained below the healthy-neurotic range. A higher number of axis I disorders and childhood histories of sexual abuse and witnessing violence were associated with a slower rate of improvement in defenses. Change in defenses within therapy by 2.5 years was highly associated with significant levels of change at 5 years in external measures of both functioning (rs=0.60) and symptoms (rs=0.58), controlling for initial levels. Change in defensive functioning in long-term psychotherapy largely follows the hierarchy of defense adaptation. The relationship to long-term improvement in outcomes suggests that defenses be considered candidates for mediating improvement in functioning and symptoms.

Practice-Based Evidence: Patients Who Did Not Respond to Group Analysis

Evidence-based psychotherapy is typically based on treatment outcome for the “average” patient in aggregate designs; reports on individual non-responders are rarely published. In this observational study, we explored factors that might have contributed to non-response in long-term dynamic group psychotherapy. Eight patients (14%) who did not change were compared with 48 treatment responders on clinical variables, and their case stories were retrospectively scrutinized for explanatory factors. The non-responders had less initial distress, stayed for shorter durations in therapy, and were more dissatisfied with their group and therapists. Based on detailed case stories, attempts are made to tease out idiographic hypotheses why each patient did not change during group analysis.

La psychothérapie dynamique dans la pratique psychiatrique : est-ce efficace ?

With the emergence of evidence-based medicine, the place of psychodynamic therapy in psychiatric practice has been questioned in recent years. This article proposes a critical review of the scientific literature on efficacy and effectiveness of brief, long-term dynamic psychotherapy and psychoanalysis in the context of psychiatric health services. An electronic search of Medline and Psychinfo was done with relevant keywords on the topic. An overview of the efficacy of psychodynamic approaches is then provided for various disorders of axis I and axis II according to the DSM-IV. The assessment of the efficacy and effectiveness of brief, long-term dynamic psychotherapy and psychoanalysis has substantially progressed in recent years. While some gaps remain to be filled in this area, it seems that psychodynamic approaches, especially brief dynamic therapy, have a comparable efficacy with other commonly used approaches.

Ask the Expert: E-mail in Communication with Patients

Back to table of contents Previous article Next article CLINICAL SYNTHESISFull AccessAsk the Expert: E-mail in Communication with PatientsGlen O. Gabbard, M.D.Glen O. GabbardSearch for more papers by this author, M.D.Published Online:1 Jan 2010https://doi.org/10.1176/foc.8.1.foc43AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail A patient in long-term dynamic psychotherapy who is also taking antidepressants for depression sends me numerous e-mails, sometimes with medication questions and other times about her relationships or the therapy session. Should I respond and, if so, how?What you describe is increasingly common in psychiatric practice. We are all getting e-mails and text messages from patients on a regular basis. We must first understand that there are no consensual guidelines regarding the use of e-mail in communication with psychiatric patients. There are three major ethical concerns to keep in mind: 1) problems inherent in the mechanics of e-mail, 2) privacy and confidentiality issues, and 3) the loss of essential elements of the clinical encounter when electronic communication is used.E-mails can be inadvertently deleted or placed on the “back burner” in a busy practice. Access to computers is not a given in the course of a psychiatrist's typical week. Patients who may be highly distressed and want to reach the psychiatrist quickly may find that the psychiatrist doesn't get to the e-mail until days later. One must always keep in mind that privacy can be compromised with e-mail. Every time an e-mail is sent there is a possibility that an unintended recipient may end up reading it. There is an illusion of privacy and confidentiality that lulls both sender and reader into a false sense of security. Computers are frequently left on both in the home and in the office, and a slip of the finger can result in a breach of confidentiality. Finally, the capacity to make clinical judgments is severely compromised when one's information is limited to words on a screen. One cannot see the patient, assess nonverbal aspects of the communication, and reach sound clinical conclusions from an e-mail. Moreover, e-mail communication, by its very nature promotes transference distortion. A busy physician may not have the time to respond to an e-mail message in a long and reflective fashion, and a terse response may be misread by a distressed patient.In light of the complexities of using e-mail:, Kassaw and Gabbard (1) have recommended several guidelines: 1. The patient should initiate the request to include e-mail as part of the therapeutic relationship. If the psychiatrist initiates it, the patient may feel trivialized or assume that some information does not require face-to-face discussion.2. The psychiatrist must also define with the patient what information or questions are mutually acceptable for communication on e-mail.3. Psychiatrists should also consider obtaining informed consent before using e-mail as part of the therapeutic relationship. This discussion should include things such as expectations of time for response, mutually agreed-upon content, security mechanisms, and so forth.In my opinion, the exchanges between psychiatrist and patient should be limited to brief administrative communications about things such as appointment changes. Medication questions are complicated: they often involve psychological issues that are attributed to medication side effects or true physical problems that require assessment. These concerns need to be evaluated in person. Similarly, relationship issues that are suitable for therapy should be discussed in person so that the psychiatrist can make a thorough assessment of the themes inherent in the question.CME DisclosureGlen O. Gabbard, Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry, Baylor College of Medicine, Houston, TXReports no competing interests.ReferenceKassaw K, Gabbard G: The ethics of e-mail communication in psychiatry. Psychiatr Clin N Am 2002; 25:665–674 Crossref, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 8Issue 1 Winter 2010Pages 43-43Psychotherapy PDF download

The Sequence of Recovery in Long-Term Dynamic Psychotherapy

Psychotherapy has generally been found both efficacious and effective in producing improvement, but the sequence of recovery across different measures is less studied. A total of 53 patients with mood, anxiety, and/or personality disorders were enrolled in an effectiveness study of long-term dynamic psychotherapy of whom 49 gave some follow-up data. Follow-up interviews over a median of 5 years systematically rated 16 measures of Axis I disorders, symptoms, and functioning. Linear models estimated the rate and amount of improvement and time to recovery for each subject initially not well on each measure. The proportion recovering on each measure varied from 0% to 66.7% with self-destructive symptoms and working half-time leading, followed by self-reported measures of distress and defensive functioning, working full-time and satisfaction, then by observer-rated depression and anxiety, attaining a global assessment of functioning of 61, Axis I disorders, and social role functioning. Participants recovering on satisfaction had higher net proportions of other measures attaining recovery (46.9% versus 2.5%, p < 0.0001) compared with those not satisfied. Sustained recovery unfolds sequentially across a variety of symptoms and functioning measures and is associated with patient satisfaction.

Predictors of Treatment Duration and Retention in a Study of Long-Term Dynamic Psychotherapy: Childhood Adversity, Adult Personality, and Diagnosis

Systematic knowledge about patient characteristics that predict the duration of long-term psychotherapy is largely absent. We examined predictors of attrition, retention, and duration of long-term dynamic psychotherapy to delineate the naturalistic history of psychotherapy, specifically focusing on childhood emotional neglect and abuse, adult diagnosis, personality, and functioning as predictors. Fifty-three adults with depressive, anxiety, and/or personality disorders (PDs) were offered at least 3 years of long-term dynamic psychotherapy. The median duration of therapy for the study group was 110 sessions (95% confidence interval [CI] 52-141). Nondynamic characteristics (including demographics; most Axis I diagnoses; depression, anxiety, and distress scores; social and global functioning; and the five personality factors) did not predict number of sessions. Dysthymic disorder, presence of any PD (particularly dependent PD [DPD]), emotional neglect in childhood, and higher adaptive defense style scores predicted a greater number of sessions, while obsessive-compulsive PD (OCPD) predicted fewer sessions. Emotional neglect, DPD, higher adaptive defenses, and OCPD were each unique predictors of duration. A session frequency less than 0.7 sessions per week (36 sessions per year) was associated with a three-fold higher risk for intrinsic attrition (relative risk = 3.04, 95% CI 1.10-8.44). Childhood emotional neglect as well as adult dependency may predispose patients to remain in therapy for longer durations, while some adaptive defenses may allow patients to contain the distressing affects that might otherwise lead to early termination. It remains to be seen whether longer durations of treatments are associated with respectively greater improvement, other things being equal, and whether these findings generalize to other types of treatment.

Psychotropic Medication Use, Personality Disorder and Improvement in Long-Term Dynamic Psychotherapy

Patients receiving long-term dynamic psychotherapy often have both depression and personality disorders (PDs) and take medications concurrently. Our goal was to determine the extent of medication use in an outpatient sample and the relationships of medication use and PD status to diagnostic and symptom measures. Fifty-three patients (25 of whom were taking medications at intake) who entered a long-term psychodynamic psychotherapy study for the treatment of chronic or recurrent depression, anxiety, and/or PDs were followed up to 7 years. PD patients who received combined therapy showed significant improvement in functioning and distress, while those receiving only psychotherapy showed significant improvement in depression and distress. Non-PD patients receiving only psychotherapy showed significant improvement in functioning. Long-term dynamic psychotherapy was associated with improvement in symptoms and functioning for the sample as a whole. PD pathology and being on medications at intake acted as moderator variables: PD predicted a smaller effect size in depression and functioning, while medications predicted a smaller effect size in depression only.

Long-Term Changes in Defense Styles With Psychodynamic Psychotherapy for Depressive, Anxiety, and Personality Disorders

Objective: This study examined 1) whether patients with chronic and recurrent anxiety and depressive disorders and/or personality disorders demonstrate improvement in their defense styles with long-term dynamic psychotherapy and 2) what the relationship is between defense style change and symptomatic change. Method: Measures of defense (Defense Style Questionnaire) and symptoms and functioning were administered at regular intervals over the course of 3–5 years to adults who entered a naturalistic study of long-term psychodynamic psychotherapy. With hierarchical linear regression, the relative contributions of change in variables on the Defense Style Questionnaire to change in other outcome variables were calculated. Results: Those with high initial scores on the maladaptive and self-sacrificing defense styles improved, with effect sizes of 0.80 and 0.67, while overall defensive functioning improved, with an effect size of 0.43. The effect size of the change in score on the Global Assessment of Functioning...

Psychodynamic Therapy Alters Maladaptive Defense Styles

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessPsychodynamic Therapy Alters Maladaptive Defense StylesMark MoranMark MoranSearch for more papers by this authorPublished Online:17 Sep 2004https://doi.org/10.1176/pn.39.18.0390028Psychodynamic psychotherapy produces long-term changes in maladaptive defense styles as measured by a standardized scale. And those changes appear to correlate with improvement in symptoms.“Changes in defense styles predict improvement in symptoms, so they seem to go together,” said researcher Michael Bond, M.D., psychiatrist in chief at Sir Mortimer B. Davis Jewish General Hospital in Quebec and an associate professor of psychiatry at McGill University Faculty of Medicine.Bond and co-author J. Christopher Perry, M.D., M.P.H., acknowledged in their report in the September American Journal of Psychiatry that the naturalistic nature of their study of psychodynamic psychotherapy and the lack of a manualized therapy are limitations, and that causation of change is not possible to determine. They noted as well that some patients received medication treatment in addition to psychotherapy.But Bond emphasized that the study's use of standardized measures of defense styles, symptoms, and function administered longitudinally is a unique model for measuring aspects of change that have traditionally proven difficult or impossible to measure.“The fact that it was a naturalistic study where the patients were not highly selected and the therapists were not using manuals allowed us to look at what actually goes on in patients who come for psychodynamic psychotherapy,” Bond told Psychiatric News. “And because the treatment and the follow-up were over a course of three to five years, it allowed us to look at the ups and downs that patients undergo in therapy. This is in contrast to a study of 16 weeks that may show that someone gets better, but doesn't record whether [the patient has] a relapse one year later.”Bond said that he and Perry were “interested in symptomatic improvement, but also in structural or dynamic changes. It is not easy to measure these kinds of things. Defense mechanisms are the ways in which people mediate internal and external stress, and we wanted to know whether psychodynamic psychotherapy can change those toward a more adaptive way.”In the study, 53 subjects were referred from an outpatient clinic to the Long-Term Dynamic Psychotherapy Research Project at Jewish General Hospital. The project offered a minimum of three years of free dynamic psychotherapy to subjects who had a depressive disorder, anxiety disorder, and/or personality disorder. Patients with psychosis, organic brain disorders, or significant substance abuse were excluded.Of the 53 subjects, 41 were women. A substantial number of the subjects (40) had personality disorders, including borderline, self-defeating, avoidant, and narcissistic, while eight had “significant personality disorder traits” that were not severe enough to qualify for a diagnosis of personality disorder. Every six months during therapy, patients completed the Defense Style Questionnaire, an 88-item self-report designed to measure defense styles. These include maladaptive, image-distorting, self-sacrificing, and adaptive styles. After sessions 3, 5, 7, 9, and 11, the patients completed the California Psychotherapy Alliance Scale. The Global Assessment of Functioning and SCL-90-R (a measure of distress) was administered every six months, and patients with depression completed the Hamilton Rating Scale for Depression.Of the 29 patients who completed the study, those with high initial scores on maladaptive and self-sacrificing defense styles showed statistically significant improvement on those scales over the course of the study.Initial symptom scores on the Global Severity Index of the SCL-90-R, Hamilton, and Global Assessment of Functioning correlated significantly with initial scores on the Defense Style Questionnaire: higher defensive functioning was associated with fewer symptoms and better adjustment.Over the course of the follow-up period, which was from three to five years, subjects showed statistically significant improvement in overall mean scores on the Global Assessment of Functioning and the Global Severity Index of the SCL-90-R. The scores of subjects with depression on the Hamilton Rating Scale for Depression were statistically significantly improved after the subjects had the psychodynamic psychotherapy.Moreover, regression analysis showed that change in overall defensive functioning predicted change in symptoms and functioning. “[A]lthough we cannot determine whether defense change causes symptom change or visa versa, or whether both change as a function of some third factor, change in overall defensive functioning was a potent predictor of change in symptoms and functioning,” the authors stated in their report.Bond also noted that among the patients with personality disorder, staying in treatment appeared to be essential to improvement. He speculated that open-ended treatment may be critical to such patients, who may for conscious and unconscious reasons leave therapy early if a time limit is established.The study, “Long-Term Changes in Defense Styles With Psychodynamic Psychotherapy for Depressive, Anxiety, and Personality Disorders,” is posted online at<http://ajp.psychiatryonline.org/cgi/content/full/161/9/1665>.▪ Am J Psychiatry 2004 161 1665 ISSUES NewArchived

Change in the core conflictual relationship theme after long-term dynamic psychotherapy

This naturalistic study focuses on changes in central relationship patterns after long-term dynamic psychotherapy (mean duration = 3 years) with experienced psychotherapists. Relationship patterns before and after treatment were assessed according to the core conflictual relationship theme (CCRT) method, which includes 3 components: most frequent wish, response from others, and response of the self. Overall, the main CCRT did not change substantially after therapy. There were, however, a few significant changes for some of the standard cluster categories after therapy. Patients' flexibility regarding their use of different wishes and negative responses from others and the self increased, as did the frequency of positive responses from others and the self. The positive changes in relationship patterns were only rarely related to changes in symptoms and character pathology.

The core conflictual relationship theme (CCRT) and psychopathology in patients selected for dynamic psychotherapy

The present naturalistic study examined the relation between core interpersonal patterns measured by the Core Conflictual Relationship Theme (CCRT) method and psychopathology in 55 patients selected for long-term dynamic psychotherapy. Psychopathology was assessed by the DSM-III-R, symptom self-report, and the Karolinska Psychodynamic Profile (KAPP). Patients with different DSM-III-R diagnoses did not differ in their CCRTs abstracted from the Relationship Anecdote Paradigm interview. Furthermore, lack of flexibility (pervasiveness) in the use of different CCRT components was not associated with psychiatric symptoms. Only one significant correlation between character pathology and the CCRT was found: problems concerning the patients' experience of social significance were associated with more negative responses of other. Limitations of the CCRT method and the sample used are discussed. Die vorliegende naturalistische Studie prüfte den Zusammenhang zwischen interpesonalen Mustern - gemessen mit der ZBKT-Methode - und der Psychopathologie bei 55 Patienten, die für eine psychodynamische Langzeittherapie indiziert waren. Psychopathologie wurde mit dem DSM-III-R, Selbstbeschreibungen und dem Karolinska Psychodynamic Profile (KAPP) untersucht. Patienten mit verschiedenen DSM-III-R Diagnosen unterschieden sich nicht im Hinblick auf ihre ZBKT in einem Beziehungsinterview. Mangel an Flexibiltät bezüglich unterschiedlicher ZBKT-Komponenten stand nicht in Beziehung zu psychiatrischen Symptomen. Nur eine signifikante Korrelation zwischen Charakterpathologie und ZBKT lie ß sich nachweisen: Probleme der Patienten mit ihrer sozialen bedeutung standen in Beziehung zu negativeren Reaktionen von Objekten. Bergrenzungen der ZBKT-Methode und der Stichprobe werden diskutiert. Cette étude naturaliste examine la relation entre des patterns interpersonnels de base mesurés par la méthode du Thème Relationnel Conflictuel Central (CCRT) et la psychopathologie chez 55 patients sélectionnés pour une psychothérapie psychodynamique de longue durée. La psychopathologie a été évaluée selon DSM-III-R, par un auto-questionnaire de symptômes et par le Karolinska Profile Psychodynamique (KAPP). Les patients avec des diagnostics DSM-II-R différents n'ont pas montré de différence dans leur CCRT obtenu sur la base d'interviews RAP (Paradigme d'Anecdotes Relationnelles). Par ailleurs, le manque de flexibilité ('pervasiveness') dans l'emploi des différentes composantes du CCRT n'a pas été associé à des symptômes psychiatriques. Une seule corrélation significative entre pathologie de catarctèe et CCRT aété trouvée; une expérience de position sociale problématique a été associée à des réponses de l'autre plus négatives. Nous discutons des limitations de la méhode du CCRT et de l'échantillon. El presente estudio naturalístico examina la relación entre el núleo de pautas interpersonales medida por el método del Tema Nuclear Relacional Conflictivo (CCRT) y la psicopatología en cincuenta y cinco pacientes seleccionados para psicoterapia dinámica a largo plazo. La psicopatología se evaluó según el DSM-III-R, el informe auto-administrado de sintomas y el Perfil Psicodinámico de Karolinska (KAPP). Pacientes con diferentes diagnósticos según el DSM-III-R no difirieron en el CCRT abstraído de la entrevista Paradigma Anecdótico Relacional (Relationship Anecdote Paradigm). Más aun, la falta de flexibilidad ['pregnancia' ('pervasiveness')] en el uso de diferentes components del CCRT no estuvo asociada con síntomas psiquiátricos. Solo se encontró una correlación significativa entre la caracteropatía y el CCRT; los probelmas relacionados con la experiencia de significatividad social de los pacientes estuvo asociada con respuestas más negativas del otro. Se discuten las limitaciones del método del CCRT y de la muestra usada.

Oedipal Anxiety and Cultural Variations in the Incest Taboo: A Psychotherapy Case Study in the Nigerian Setting

This paper reports the highlights of long-term dynamic psychotherapy with an African. The case is presented of a 34-year-old Nigerian exarmy officer with the onset of panic symptoms following the death of a neighbor. This event was found to symbolize the core of his conflicts. Therapy revealed ongoing conflict with his father, with peers at work and in his marriage. There were also violations of the incest taboos in his extended and polygamous family. The psychotherapeutic process is delineated with special reference to Oedipal components. The following variations are discussed: (i) the impact of a cultural setting which enforced infancy/early childhood domicile with mother, separate sleeping quarters for the father, and later separation of all males from mother; (ii) the dynamics of growing up in a home where father has multiple wives who may function as surrogate mothers in his lifetime or, at his death, as potential wives; (iii) the vicissitudes of the incest taboo in a complex extended family that is under siege by urbanization. The therapeutic experience contrasts sharply with the experience of western psychiatrists who practiced in Nigeria two decades before.

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