Long-term Psychoanalytic Treatment Research Articles

Implicit relational aspects of the therapeutic relationship in psychoanalytic treatments: an examination of linguistic style entrainment over time

Objective: In an attempt to operationalize an implicit aspect of the therapeutic relationship, this study assesses reciprocal linguistic style entrainment (rLSM) between the patient and therapist. rLSM is defined as the dynamic adjustment of function word usage to synchronize or to be in rhythm with another person as they change over time. Method: In this exploratory study, levels of rLSM per talk turn were analyzed for 540 sessions of 27 long-term psychoanalytic treatments in relation to treatment outcomes. Results: Within sessions, rLSM appeared to decrease by the end of sessions and followed a negative linear trajectory, βlinear = −0.0002, SE < .001, t = −13.04, p < .001. Between sessions, rLSM showed significant variability such that neither a linear, nor a quadratic, nor a cubic trend line fit the session-by-session change over treatment. On average, therapist talk turns had significantly lower rLSM than patient talk turns, while accounting for the nested nature of the data using multilevel models βSpeakerT = −0.033, SE = 0.009, t = −3.65, p < .001. Levels of rLSM did not relate to treatment outcome. Conclusion: Most of the rLSM variance was at the within-patient and within-session level. rLSM was no indicator of psychoanalytic treatment outcomes.

An empirical exploration of psychoanalytic processes and outcomes in 27 long-term psychoanalytic treatments

An empirical exploration of psychoanalytic processes and outcomes in 27 long-term psychoanalytic treatments

Cost-effectiveness of long-term psychoanalytic psychotherapy for treatment-resistant depression: RCT evidence from the Tavistock Adult Depression Study (TADS)

BackgroundTreatment-resistant depression (TRD) accounts for a large fraction of the burden of depression. The interventions currently used are mostly pharmacological and short-term psychotherapies, but their effectiveness is limited. The Tavistock Adult Depression Study found evidence for the effectiveness of long-term psychoanalytic psychotherapy (LTPP) plus treatment as usual (TAU), versus TAU alone, for TRD. Even after a 2-year follow-up, moderate effect sizes were sustained. This study assessed the cost-effectiveness of this LTPP + TAU. MethodsWe conducted a within-trial economic evaluation using a Bayesian framework. ResultsQuality-adjusted life years (QALYs) were 0.16 higher in the LTPP + TAU group compared with TAU. The direct cost of LTPP was £5500, with no substantial compensating savings elsewhere. Overall, average health and social care costs in the LTPP + TAU group were £5000 more than in the TAU group, employment rates were unchanged, and effects on other non-healthcare costs were uncertain. Accordingly, the incremental cost-effectiveness ratio was ≈£33,000/QALY; the probability that LTPP + TAU was cost-effective at a willingness to pay of £20,000/QALY was 18 %. LimitationsThe sample size of this study was relatively small, and the fraction of missing service-use data was approximately 50 % at all time points. The study was conducted at a single site, potentially reducing generalizability. ConclusionsAlthough LTPP + TAU was found to be clinically effective for treating TRD, it was not found to be cost-effective compared with TAU. However, given the sustained effects over the follow-up period it is likely that the time horizon of this study was too short to capture all benefits of LTPP augmentation.

Language style matching in psychotherapy: An implicit aspect of alliance.

In an attempt to operationalize an implicit aspect of the therapeutic alliance, this article proposes the use of the innovative, objective, and time-efficient analysis of language style matching (LSM; Niederhoffer & Pennebaker, 2002). LSM, defined as the degree of similarity in rates of function words in dyadic interactions, is thought to reflect the extent to which conversational partners are automatically coordinating language styles to achieve a common goal. Although LSM has often been researched in the context of everyday conversations, little is known about the matching of clients and therapists' language style in the psychotherapy process. To demonstrate the clinical usefulness of the LSM approach in psychotherapy, 2 exploratory examples of the application of LSM in long-term psychoanalytic treatments are provided. First, LSM analyses per session and per speaking-turn are described for psychotherapy data of 140 sessions of 7 long-term psychoanalytic treatments in relation to outcome measures. Then, a case study is described in which LSM is triangulated with an observer-rated measure of working alliance in relation to outcome measures. These 2 demonstrative empirical examples were explorative in character and illustrate how LSM might tap into an implicit aspect of the therapeutic relationship, different from the working alliance measured by observers, and relevant for treatment outcome. Future larger-scale psychotherapy studies into the relationship between these implicit aspects of the alliance and treatment outcome and relevant clients and therapists' variables are warranted. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Therapeuten als neue und andere Objekte: Welche Therapie für Borderline-Patienten?

Therapists as new and different objects: Which therapy for Borderline personality disorder? This paper looks at the changed social conditions in which today's children grow up. Using examples, it is shown how this situation corresponds to some of the problems with which Borderline patients struggle. In the face of an increase in short-term forms of therapy, the author underlines and discusses the continuing importance of intensive, long-term psychoanalytic treatment for Borderline patients.

Celebrating Forty Years of Clinical Social Work

This March 2013 issue marks the 40th anniversary of the Clinical Social Work Journal (CSWJ). The brainchild of Mary Gottesfeld, a clinical social worker at the Jewish Board of Family and Children’s Services in New York City, the CSWJ was established in 1973 as a publication forum for the National Federation of Societies for Clinical Social Work (NFSCSW). Mary served as the CSWJ’s Founding Editor until 1981, and during her tenure published numerous articles on ego psychology and its application, as well as the impact of deinstitutionalization on treatment, the efficacy of psychotherapy, and the emergence of behavioral therapies. As the NFSCSW grew in membership, the CSWJ enjoyed a substantial increase in its readership. Mary’s untimely illness necessitated her turning the reigns of the editorship to Jean Sanville, a nationally known psychoanalyst and scholar who presided skillfully over the CSWJ and its editorial board for 15 years. Jean viewed psychoanalytic treatment and clinical social work as kindred approaches, and the articles published during her tenure reflected this position. No longer was ego psychology the dominant paradigm. Object relations theory, especially applied to the understanding of borderline personality disorder and countertransference reactions, were major themes for nearly a decade. Social issues and diagnostic entities such as AIDS, sexual abuse, and substance abuse came to the fore in the CSWJ during the 1990s. Managed care intruded into the clinical hour, as did concerns regarding licensure, professionalism, and the relevance of long-term psychoanalytic treatment in a short-term, evidence-based practice (EBP) world. During Carolyn Saari’s ten-year tenure as Editor-inChief, she and the editorial board served as able stewards of clinical social work. Keeping loyal to the original intent of the journal, these issues were addressed and illustrated through a largely psychodynamic lens. The dissolving of the NFSCSW coincided with the change of Editors. Carolyn’s daunting charge to me in 2007 was to find creative ways to keep the CSWJ current with professional and world developments without abandoning its core psychoanalytic social work mission. While a crucial component of contemporary social work practice, the psychodynamic orientation has had to share the stage with EBPs and related manualized treatments, as well as shortterm integrative treatments for specialized populations. Proponents of psychoanalytic social work have also had to combat the general perception that psychodynamic treatment is anachronistic and suitable only for the worried well. Coupled with extrinsic factors as varied as HIPAA regulations and global terrorism, the CSWJ has responded by broadening the definition of clinical social work to encompass all contemporary models and treatment approaches that benefit clients, especially those populations most at-risk. Special issues on empirically supported attachment-based therapies for adults and children, emblematic of the current psychoanalytic zeitgeist, have been followed by issues devoted to integrative treatment, EBP research, international trauma, family therapy, and agency-based practice with vulnerable populations to name a few. It is therefore fitting that this March 2013 special issue is devoted to culture and creativity in contemporary psychoanalytic thought. A comparison to the first issue of the CSWJ in March 1973, this issue attests to the evolution of the psychoanalytic approach and its rightful place along side EBP in the clinical social work armamentarium. C. Tosone (&) New York University Silver School of Social Work, New York, NY, USA e-mail: ct2@nyu.edu

Designs for Studying the Effectiveness of Long-Term Psychoanalytic Treatments

Long-Term Psychoanalytic Treatments (LTPT) include both long-term psychoanalytic psychotherapy (LTPP) and psychoanalysis (PsAn). Current opinion seems to be that there is some evidence for the effectiveness of LTPP, but none for that of PsAn. This may be due in part to researchers not balancing the level of evidence of randomized controlled studies (RCTs), cohort studies, and pre-post studies with patients' acceptance of these various research designs used in studying the effectiveness of LTPT. After a review of the merits of eight possible control conditions for LTPT in RCTs and cohort studies, and a consideration of the limitations and merits of pre-post studies, it was found that RCTs pair high levels of evidence with limited degrees of patient acceptance, especially where PsAn is concerned. Cohort studies appear to provide at most a moderate level of evidence. Their acceptability is hardly better than that of RCTs, as it depends on the acceptability of control conditions similar to those of RCTs. The acceptability of pre-post studies is much better, but they can provide, at most, a moderate level of evidence. Apart from randomization, they can meet all methodological criteria for high-quality research (often they do not, but there are ways to correct this). In summary, in the long-term treatment of complex mental disorders with LTPT, RCTs often pair a high level of evidence with limited patient acceptance of the method. Compared to RCTs, cohort studies show a lower level of evidence without much gain in acceptability. Pre-post studies pair the highest level of acceptability with the lowest level of evidence of the three designs. Limited acceptability is not to be confused with no acceptability, nor moderate level of evidence with none.

Posters

In recent years psychoanalytically oriented researchers have invested in outcome studies to provide empirical evidence for the effectiveness of their treatments. This has led to a considerable (and still growing) body of research about the effectiveness of long-term ambulatory psychoanalytic treatment (Leichsenring and Rabung 2008; Shedler 2010). The present study investigated whether long-term psychoanalytic treatment (psychoanalysis and psychoanalytic psychotherapy) is effective in reducing symptomatic distress and improving personality functioning.

The Role of Mentalization in the Psychoanalytic Treatment of Chronic Depression

Mentalization has been proposed as a key concept in understanding therapeutic change in patients with Borderline Personality Disorder (BPD). However, little is known about mentalization in chronic depression. This study investigated the role of mentalization in the long-term psychoanalytic treatment of chronic depression. Mentalization measured with the Reflective Functioning Scale (RFS) was examined in patients with chronic depression (n = 20) in long-term psychoanalytic treatment and compared to healthy controls (n = 20). Results show that global RF scores did not differ significantly between patients and controls. However, depressed patients tended to have lower RF scores concerning issues of loss. Furthermore, RF was unrelated to symptoms and distress as assessed by the Beck Depression Inventory (BDI) and the SCL-90. RF did not predict therapeutic outcome as measured with the BDI but predicted changes in general distress after 8 months of psychoanalytic treatment as measured by the SCL-90. Moreover, correlations between RF and the Helping Alliance Questionnaire indicated that patients with higher RF were able to establish a therapeutic alliance more easily compared to patients with low RF.

The Effects of Long-Term Psychoanalytic Treatment on Healthcare Utilization and Work Impairment and Their Associated Costs

Long-term psychoanalytic treatment is perceived as an expensive ambulatory treatment for mental illnesses. However, there are indications that psychoanalytic treatment can result in cost savings in the long term. In this study, we investigated the effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and calculated the associated societal costs. We assessed healthcare utilization and work impairment of patients before, during, and after long-term psychoanalytic treatment (N=231). Our results show that the difference in total costs associated with healthcare utilization and work impairment between pre- and post-treatment was euro2444 (U.S.$3070 using average exchange rates for 2006, the year for which these data were calculated) per person per year. Two years after treatment termination, these cost savings had increased to euro3632 ($4563) per person per year. This indicates that we can expect decreased consumption of medical care and higher work productivity right after psychoanalytic treatment, but also that longterm psychoanalytic treatment can generate economical benefits in the long run. However, we cannot conclude that all invested costs will be earned back eventually. More research is needed on the cost-effectiveness of psychoanalytic treatment.

Symptomen en persoonlijkheidsproblemen voor, tijdens en na langdurige psychoanalytische behandelingen: een multiple-cohort studie

Symptoms and personality problems before, during and after long-term psychoanalytic treatment: A multiple-cohort study

A cost-utility analysis of psychoanalysis versus psychoanalytic psychotherapy

Despite the considerable and growing body of research about the clinical effectiveness of long-term psychoanalytic treatment, relatively little attention has been paid to economic evaluations, particularly with reference to the broader range of societal effects. In this cost-utility study, we examined the incremental cost-effectiveness ratio (ICER) of psychoanalysis versus psychoanalytic psychotherapy. Incremental costs and effects were estimated by means of cross-sectional measurements in a cohort design (psychoanalysis, n = 78; psychoanalytic psychotherapy, n = 104). Quality-adjusted life-years (QALYs) were estimated for each treatment strategy using the SF-6D. Total costs were calculated from a societal perspective (treatment costs plus other societal costs) and discounted at 4 percent. Psychoanalysis was more costly than psychoanalytic psychotherapy, but also more effective from a health-related quality of life perspective. The ICER--that is, the extra costs to gain one additional QALY by delivering psychoanalysis instead of psychoanalytic psychotherapy--was estimated at 52,384 euros per QALY gained. Our findings show that the cost-utility ratio of psychoanalysis relative to psychoanalytic psychotherapy is within an acceptable range. More research is needed to find out whether cost-utility ratios vary with different types of patients. We also encourage cost-utility analyses comparing psychoanalytic treatment to other forms of (long-term) treatment.

Turbulent Contextualism: Bearing Complexity Toward Change

Recently, psychoanalysis has approbated physical science concepts to explain the momentum of clinical work. This article continues in that tradition with turbulent contextualism, a theoretical system that describes the necessary yet destabilizing and chaotic elements of change, which occur in the psychoanalytic process. With turbulent contextualism, the emergence of new solutions in the psychoanalytic environment is connected to the capacity of the psychoanalyst and the patient to bear complexity and be able to accept the nonlinear nature of change. The article concludes with an application of turbulent contextualism to two clinical cases. The first case details the use of this model in a long-term psychoanalytic treatment. The second case uses the same ideas to explore my own personal development and self-definition, which were consolidated through the process of writing this article.

Clinical significance of long-term psychoanalytic treatment

The present study evaluated the clinical significance of long-term psychoanalytic treatment in four groups of about 60 patients in different phases of treatment (before, during, after, follow-up) with normative comparisons on four symptom questionnaires (SCL-90, BDI-II, STAI, IIP-64) and two personality assessment instruments (MMPI-2, Rorschach-CS). In each group, the proportion of patients with clinically elevated scores was calculated by comparing their scores with clinical and nonclinical reference groups for each instrument. The authors also calculated a combined percentage of clinically elevated scores based on the six instruments as a conservative estimate of improvement to nonclinical levels after long-term psychoanalytic treatment. Compared to pretreatment levels, the authors found a significant decrease in the percentage of clinical cases after treatment. For the personality assessment, these results became even more evident at follow-up. It appears that long-term psychoanalytic treatment was clinically significant for patients with chronic mental disorders. In the discussion, the authors point out that the evaluation of clinical significance at group level should be followed by an examination of individual changes over a longer period of time.

Handle with Care: The Psychoanalysis of a Touchy Case

This is a case of the long-term psychoanalytic treatment of a 59-year-old, gay man. The patient initially presented with anxiety symptoms related to caring for a depressed, disabled long-term partner. Throughout the treatment, the patient carried feelings of entitlement and perfectionism that made straightforward interpretations difficult. An important theme of the treatment was the patient's coming to terms with the limits of his ability to control his partner's moods, and both of them accepting the disabling nature of the partner's depression. The treatment also focused on the patient's feelings of shame, self-esteem, and entitlement. As he worked through those feelings, the patient developed an increased capacity to appropriately assert himself in his relationship, in his work, and in the treatment relationship.

Identifying clinical cases among patients assigned to psychoanalytic treatment

The present study compared 89 patients assigned to long-term psychoanalytic psychotherapy or psychoanalysis in the Netherlands with psychiatric and nonclinical norm groups with regard to symptoms and personality pathology as assessed with six instruments. Patients filled in four self-report questionnaires (Symptom Checklist-90-Revised [SCL-90-R], Beck Depression Inventory-II [BDI-II], State-Trait Anxiety Inventory [STAI]) and underwent a personality assessment (Minnesota Multiphasic Personality Inventory-2 [MMPI-2], Rorschach-CS). The authors used statistically defined cutoff values for each measure. For each instrument separately, about 50% of the patients reported clinical levels of psychopathology, some patients being more depressed and others reporting other symptoms. By combining the test scores of the different instruments, the authors found that 91% of the patients were identified as clinical cases. Compared to psychiatric norm groups, these patients appeared to report lower levels of symptom distress, but similar levels of personality pathology. The next step will be to investigate the level of improvement after long-term psychoanalytic treatment.

Long-Term Psychoanalytic Therapy as a Life-Saving Procedure

A dramatic long-term psychoanalytic treatment of a psychotic character disorder is presented in detail. This patient began therapy with a long standing history of an eating disorder for which she had received many hospitalizations and forms of treatment without any success. She was in a deep despair and as a last resort agreed to a psychoanalytic therapy. During the many years of treatment the eating disorder completely resolved but was replaced by a series of very dangerous accidents that occurred each time she was betrayed and disappointed by a boy friend. This went on pari passu with a deepening understanding of her childhood and her psychodynamics but the middle of the therapy was very stormy and required tenacious efforts to maintain the treatment. The self-destructive behavior was traced to early and profound childhood disappointments and a sense that these were her fault because she was so unlovable and therefore deserved punishment. A dangerous stalemate developed in the treatment after a number of years. The analyst presented the case to colleagues several times and wrote it up in detail, which enabled him to understand his own countertransference and resolve it. This resulted in a dramatic change in the patient and a very favorable and happy ending to this very difficult treatment after 15 years. Although the author believes all patients in psychoanalysis should be approached with as neutral and objective a stance as possible, emphasizing free association and dream material in order to interpret the crucial childhood determinants of the patient's psychopathology, in cases such as psychotic character disorders the outcome clearly also depends on interpersonal factors. The case illustrates the deep partly conscious and partly unconscious interaction between a patient and her analyst over many years of treatment and the profound effect this has on the outcome. It underscores the importance of patients being allowed to heal in their own way and in their own time without intrusion or interference from the analyst. It also demonstrates the crucial importance of long-term psychoanalytic therapy as a life-saving procedure in cases where it is appropriate in spite of the great amount of time and expense involved.

Klinisch geval of worried well? Een beschrijving van patiënten voorafgaand aan psychoanalytische behandeling

The present study investigated which mental health aspects were clinically affected in 170 patients who were assigned to long-term ambulatory psychoanalytic treatment, in other words to what extent these patients were sick or distressed. At intake, patients filled in four self-report questionnaires (SCL-90-R, IIP-64, BDI-II, STAI) and underwent a psychodiagnostic assessment consisting of the MMPI-2 and the Rorschach-CS. In order to see how many patients had clinically significant mental health problems in our population, we used the non-clinical norm scores for each measure and the ‘caseness criterion’. After combining the test scores of the questionnaires and personality assessment we found that 91% of our patients were identified as clinical cases. Compared to other ambulatory psychotherapy patients, patients assigned to psychoanalytic treatment reported less symptoms but with regard to personality problems they presented similar levels of psychopathology.

Expanding the Evidence Base for the Cost-Effectiveness of Long-Term Psychoanalytic Treatment

A study into the effectiveness of psychoanalytic treatment has to make choices about the theoretical framework, instruments and a research design. The current poster aims to explain these choices. The theoretical framework is attachment theory including theoretical extensions regarding mental functioning. The choice of instruments includes theoretically based instruments to assess interpersonal and intrapsychic change as well as a-theoretical instruments assessing symptomatic functioning and therapeutic process. Furthermore, we have chosen a quasi-experimental longitudinal cohort design with repeated (overlapping) measurements. This multicenter project will provide relevant information about the (cost)effectiveness of long-term ambulatory psychoanalytic treatments and can increase the transparency of treatment selection criteria . The systematic monitoring of patients will also be of great importance to the patients themselves, because it will provide a detailed evaluation of their treatment progress. The use of a coherent theoretical framework, appropriate instruments, and a quasi-experimental design in a large naturalistic sample might provide some answers to several questions regarding the effectiveness of psychoanalysis versus psychoanalytic psychotherapy versus no-treatment.

Can Psychoanalysis Become Empirically Supported?

The article discusses the application of the ideas of evidence-based medicine or empirically supported treatment to the field of psychoanalysis. The author argues that empirical support is gradual rather than categorical, and that the randomized clinical trial (RCT), which is commonly heralded as the appropriate method of support, confounds patient suitability factors with treatment 'as such'. As a consequence of the exclusive reliance on the RCT, empirical validation of psychological treatments has generally favoured cognitive-behavioural treatments, although there is ample evidence - albeit non-RCT - for the beneficial effects of short-term and long-term psychoanalytic treatment. The author argues for a suitability matching approach to empirical validation, where each treatment is tested, as powerfully as feasible, on samples based on selfselection (patient's choice, clinical assignment, suitability judgments etc.). The paper concludes by referring to two recent studies, indicating that there is reason to evaluate alleged empirical support with caution.