Long-term Psychotherapy Research Articles

Embracing darkness: clinical work with adolescents and young adults addicted to sexual enactments

This paper described common themes and transitions in the treatment of adolescents and young adults presenting as addicted to sexual enactments. Central to their experience is a highly addictive reliance on a bad object, which both enables and relies upon sexually perverse enactments. The paper follows the therapeutic process with patients seen in either group or individual long-term psychotherapy. Their experience is understood in the context of theories central to the work at the Portman Clinic relating to perversion and addiction, combined with some ideas from the field of criminology. Patients usually start by noticing their relationship with their compulsive behaviour, moving from a passive stance to a perception of themselves as active agents. They discover moments that are described as ‘pressing a button’, at which they move from passivity to taking perverse action. Those insights lead to a slowing down of the addictive cycle and emergence of phantasies, core complex anxieties and even hopes, all desperately avoided by taking sexualised action. The paper follows a pathway of change and transformation, which when successful enables patients to reduce or cease addictive behaviours by coming in contact with a good object, enabling both emotional pain and the experience of potency and hope.

Psychosocial interventions for self-harm in adults.

Background: Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm. Objectives: To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH. Search methods: The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). Selection criteria: We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services. Data collection and analysis: We used Cochrane's standard methodological procedures.

Patients' pre-treatment interpersonal problems as predictors of therapeutic alliance in long-term psychodynamic psychotherapy

Information on how the patient's interpersonal problems predict alliance development during long-term therapy is lacking. The aim of this study was to explore how the patient's pre-treatment interpersonal problems predict the development of alliance in long-term psychotherapy. Altogether 128 adult outpatients experiencing mood or anxiety disorder were assigned to long-term psychodynamic psychotherapy in the Helsinki Psychotherapy Study. The Inventory of Interpersonal Problems (IIP) total score and the eight octant scores, assessed at baseline, were used as predictors. The trajectories of change in patient- and therapist-rated Working Alliance Inventory (WAI) were used as outcome measures at 7, 12, and 36 months of follow-up after baseline. Study of the changes by time showed that the patient-rated alliance was significantly improved by the 36-month follow-up, i.e. the most usual end-point of therapy, in persons with higher pre-treatment level of the IIP total score. Low total IIP score and low to moderate level of hostile type problems showed no slope of improvement of patient-rated alliance during follow-up. The therapist-rated alliance showed a similar course as the patient-rated alliance with the exception of a faster improvement for higher IIP scores. In conclusion, a higher level of patients' interpersonal problems predicted favorable alliance development.

‘It’s silly these doors don’t open’: a six-year-old girl emerges from a chronic state of emotional withdrawal

This clinical paper explores the way in which the first two years of a long-term psychotherapy helped six-year-old Anna to lessen her retreat into a chronic withdrawn emotional state. Over the course of the first year she would occasionally pick up the fridge from the doll’s house and try to open the doors, but because the fridge was actually a block of wood the doors could not open. In treatment, this inquiry came to represent the difficulties of engaging and making contact with a baby who found it very hard to feed. The author describes how, as Anna entered into a therapeutic relationship, it slowly became clear that there was an inner world jam-packed with persecutory anxieties and a family history of unmourned loss and trauma. Through fear Anna slammed the doors to her mind – to knowing herself – and by not feeding, Anna starved herself of opportunities for mental growth. It took some time for her to state, “it’s silly these doors don’t open, they should”. In the discussion of this clinical material the author draws on the work of Francis Tustin, Alessandra Piontelli and Marguerite Reid to consider the link between intergenerational and prenatal trauma and subsequent emotional disturbance in the child.

The Lausanne Trilogue Play within the outcome evaluation in infant mental health: a preliminary report

This study aims to contribute to the scientific debate about the evaluation of the intervention in infant mental health and presents the main results after one year of intervention based on integrated types of treatments (psychodynamic psychotherapy for the child/adolescent, parental support and observation and assessment of family interactions). Furthermore, the study aims to explore the use of the Lausanne Trilogue Play (LTP) as a new assessment tool for planning the of treatments. The sample consists of 23 children and adolescents, aged between 4 and 17 years old, and their families, attending the Infancy, Adolescence and Family Service, Local Health Unit 16 of Padua due to their psychopathological problems. In order to assess their psychological conditions we used the Child Behavior Checklist (CBCL) to evaluate psycho-behavioral problems and the LTP to assess family interactions. The CBCL was used at the time of the diagnostic assessment (T0) and after 12 months of treatment (T12). Concerning the application of LTP, the sample was divided randomly in two groups: one where LTP was used in two different time intervals during therapy (T0 and T12) and another one where it was used in three different time intervals during therapy (T0, T6 and T12) with a video-feedback intervention at time T6. Results report a favorable outcome in regards of the gravity of patients’ symptoms, displaying, after one year of treatment, a statistical significant decrease in the clinical level of internalizing symptoms. In terms of family interactions, results show stability within the family patterns except for a statistically significant deterioration in the management of interactive mistakes. Regarding the use of LTP as evaluator of the above intervention, the study shows that the assessment of family’s interactions during long-term psychotherapy helps clinicians focus the intervention on those aspects that remain dysfunctional. These results and the possible interpretations, however, emphasize the need for further studies on this topic.

Medical Approach to the Management of Traumatized Refugees.

Refugees are a highly traumatized and culturally diverse group of patients who present many clinical challenges. Refugees have a high prevalence of traumas from torture, ethnic cleansing, and the effects of long civil wars. The most common diagnoses associated with the effects of such traumas are posttraumatic stress disorder (PTSD) or PTSD with comorbid depression; however, psychosis and neurocognitive disorders are also common. For those with PTSD, a suggested treatment approach is long-term supportive psychotherapy with drug treatment directed at reducing the most disruptive symptoms, such as insomnia, nightmares, and irritability or psychosis. The author recommends a sedative tricyclic antidepressant, clonidine or prazosin, and aripiprazole as a useful combination of medications to provide rapid relief. In addition to PTSD, long-term studies indicate a high prevalence of diabetes and hypertension in traumatized refugees. It is therefore important to perform a thorough evaluation for these disorders that includes the measurement of blood pressure and a blood test for diabetes. When managed with such a medical approach, refugees are generally accepting of psychiatric treatment and can obtain relief from the symptoms associated with the massive trauma and losses they have experienced.

Pro Bono Psychotherapy With Survivors of Intimate Partner Violence

This article describes a program called “Connect and Change” in which psychotherapists in private practice offer long-term psychotherapy to women who have experienced intimate partner violence. The program is for women who cannot pay for therapy on their own.

The impact of psychotherapy treatments of different length and type on health behaviour during a five-year follow-up

Objective: The aim of this study was to investigate the influence of psychotherapy treatments of different lengths, number of sessions, and type on health behaviour. Method: A total of 367 patients were monitored for their health behaviour (alcohol consumption, body mass index), serum cholesterol (total and HDL), smoking and exercise) for five years from the start of the therapy. The effectiveness of solution-focused therapy, short-term psychodynamic psychotherapy, and long-term psychodynamic psychotherapy (LPP) was examined in a randomized clinical trial, while the LPP group and the non-randomized psychoanalysis (PA) group were compared in a naturalistic design. Results: During the follow-up, an improvement was seen with regard to alcohol consumption, serum HDL cholesterol, and smoking in the LPP and PA groups. No notable differences in health behaviour between the two groups were found, however. During the last two years of the follow-up, changes towards higher alcohol consumption and higher total serum cholesterol levels were observed in the short-term therapy groups. Conclusions: The impact of PA and LPP on health behaviour did not differ, whereas the changes were less health promoting in short-term psychotherapy. Large-scale studies are needed to confirm these findings.

Glance Stealing and Dissociation: A Long-term Psychotherapy Case

Depersonalization is one of the symptoms of dissociative disorder, which usually occurs in adolescence. It is a chronic condition of detachment from self and surrounding. The main purpose of this research is to analyze a long-term psychotherapy case in order to explore the transformation of the client's problems during the process and the progress of therapy. This research adopts the method of narrative analysis of the qualitative research. The client is a 20-year-old male junior student in college. The symptoms of panic, depersonalization, and derealization coexist. The client has received psychotherapy once a week from 2008 to 2010 for 57 therapy sessions in total. The recordings of the therapy sessions are transcribed and coded for the analysis of the client's transformation during the process of psychotherapy. The results of this research show that the level of the client's anxiety was lowered after psychotherapy. He was given a chance to express and integrate the negative feelings in the relationships. He had lessened the discussion on symptoms and shifted the focus to interpersonal relationships.

The outcome of short- and long-term psychotherapy 10 years after start of treatment.

Empirical evidence on whether patients' mental health and functioning will be more improved after long-term than short-term therapy is scarce. We addressed this question in a clinical trial with a long follow-up. In the Helsinki Psychotherapy Study, 326 out-patients with mood or anxiety disorder were randomly assigned to long-term psychodynamic psychotherapy (LPP), short-term psychodynamic psychotherapy (SPP) or solution-focused therapy (SFT) and were followed for 10 years. The outcome measures were psychiatric symptoms, work ability, personality and social functioning, need for treatment, and remission. At the end of the follow-up, altogether 74% of the patients were free from clinically elevated psychiatric symptoms. Compared with SPP, LPP showed greater reductions in symptoms, greater improvement in work ability and higher remission rates. A similar difference in symptoms and work ability was observed in comparison with SFT after adjustment for violations of treatment standards. No notable differences in effectiveness between SFT and SPP were observed. The prevalence of auxiliary treatment was relatively high, 47% in SFT, 58% in SPP and 33% in LPP, and, accordingly, the remission rates for general symptoms were 55, 45 and 62%, respectively. After 10 years of follow-up, the benefits of LPP in comparison with the short-term therapies are rather small, though significant in symptoms and work ability, possibly due to more frequent use of auxiliary therapy in the short-term therapy groups. Further studies should focus on the choice of optimal length of therapy and the selection of factors predicting outcome of short- v. long-term therapy.

The significance of the personality traits of schizophrenic patients and their therapists for the therapeutic relationship.

To analyse: 1) the associations between the therapists' and patients' assessments of the relationship, 2) the relationship between the personality traits of the therapists the personality traits of the patients and their assessments of the relationship, 3) the relationship between age, sex and the personality traits of both groups and their assessment of the relationship. 34 patients in long-term psychotherapy and their 11 therapists were investigated. The Dyadic Therapist-Patient Relationship Questionnaire, The Costa and McCraeea's NEO-FFI Personality Inventory, Pearson coefficients of correlation and the regression analysis were used. The therapists' sense of professionalism was associated with the patients' acceptance of them (p=0.032). Therapists in whom the traits of Extroversion and Openness were more prominent accepted their patients more often (p=0.006; p=0.041), felt more professional (p=0.000; p=0.023) and more rarely felt uncertain in the relationship (p=0.013; p=0.048). Patients in whom the trait of Conscientiousness was more prominent more rarely rejected therapists (p=0.004) or perceived them as uncertain (p=0.007). A higher level of Neuroticism in patients was associated with greater uncertainty in the relationship on the part of therapists (p=0.039). 1) Extroversion and Openness of therapists are associated with their attitude to patients 2) Conscientiousness and Neuroticism of patients are associated with their perception of therapists as well as with therapists' experience of the relationship 3) There is a positive influence on the therapeutic relationship when the patient is younger and the therapist older and female.

Guideline-oriented treatment of alcohol-related disorders

Alcohol use disorders (e.g. abuse and dependence) account for a plethora of consequences for affected individuals and for a substantial proportion of the overall burden of disease for the community. To date, existing treatment options are either poorly known by doctors or they are not fully applied and only approximately 15% of potential patients are treated with a mean latent period of 10 years between early symptoms and the first intervention. So-called S3 treatment guidelines were recently developed to close this gap. Representatives of more than 50 learned societies, families and patients were involved. A systematic literature search from 2005 to 2012 was performed and more than 120 recommendations were made. Financing came exclusively from those societies and the academic and treatment institutes involved.This article summarizes the recommendations pertinent for psychiatrists and include early detection and intervention, acute withdrawal and long-term psychotherapy and pharmacotherapy. Classical and new treatment goals are discussed. If the new guidelines were properly applied an increase in patients receiving treatment to 30-40% could be expected, which would improve the quality of lives of affected persons and their families and in Germany would save several thousand lives per year.

The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up

Both short-term and long-term psychotherapies are used extensively in treating different mental disorders, but there have been practically no attempts to compare their cost-effectiveness. The aim of this study, which is part of the Helsinki Psychotherapy Study, is to assess the cost-effectiveness of two short-term therapies compared to that of a long-term therapy. In this study 326 outpatients suffering from mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP) or to long-term psychodynamic psychotherapy (LPP). Psychiatric symptoms and working ability were assessed at baseline and then 4–9 times during a 5-year follow-up using eight widely used measures including e.g. Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), Symptom Check List, anxiety scale (SCL-90-Anx), Hamilton Anxiety Rating Scale (HARS), Symptom Check List, Global Severity Index (SCL-90-GSI), and the Work-subscale (SAS-Work) of the Social Adjustment Scale (SAS-SR). Both direct and indirect costs were measured. During the 5-year follow-up period statistically significant improvements were observed in all health indicators in all therapy groups. At first the recovery was faster in the short-term therapy groups than in the LPP group, but taking the whole follow-up period into account, the effectiveness of the LPP was somewhat greater than that of the short-term therapies. Especially the direct costs were, however, much higher in the LPP group than in the short-term therapy groups. Thus the long-term therapy can hardly be regarded as cost-effective compared to short-term therapies when patients are randomized to the therapy groups.

A Self Psychologist Approaches Retirement: “Forced” Termination with Highly Vulnerable Clients

Since its inception in 1973, Clinical Social Work Journal has consistently emphasized the intersubjective nature of the treatment process and the significance of the therapist’s conscious and unconscious contributions to it. In keeping with this fundamental tenet of clinical social work, which is now endorsed by virtually all psychotherapy disciplines, it is important that we acknowledge our own feelings when preparing for eventual retirement if we are to respond optimally to our clients’ feelings. In this paper, I review both the literature on “forced” terminations and the self psychology literature on termination. Three clinical vignettes are then presented to illustrate the application of these ideas to my work with vulnerable clients in long-term psychotherapy. The clinical material highlights how early introduction of the eventual termination, combined with consistent use of the empathic mode of understanding, can promote structure building and thereby enhance the therapeutic potential of the termination phase, even with clients most vulnerable to pathological regression and fragmentation following loss of the therapist.

The Omnipotence of the Psychoanalyst: Thoughts on the Need to Consider Retirement.

T he issue of retirement in the psychoanalytic profession is a rather delicate and usually unspoken matter. In fact, a recent paper by Norman Clemens (2011a) is titled “A Psychiatrist Retires: An Oxymoron?” On many occasions nonpsychoanalytic colleagues and friends have asked about my own plans for retirement, but I cannot think of one instance when a psychoanalytic colleague asked me when I was planning to retire. It is a question that had never occurred to me until rather recently. I had thought that my practice would eventually close through attrition. In fact, over the past several years I was working only twenty to twenty-five treatment hours a week. I had stopped accepting new analytic patients about fifteen years ago, except for some time-limited reanalyses, and was still working with some long-term analytic patients and several psychotherapy patients, as well as a few candidates and graduates in supervision. Finally, though, a series of noncatastrophic personal and family medical problems made me realize that it was time to formally end my psychoanalytic practice of fifty years. Analysts apparently plan to keep working until they are no longer able to function—and here lies the major problem. There are isolated stories of their continuing to work past the age of one hundred. More frequent are stories of elderly analysts or supervisors falling asleep, forgetting important material about the patient, and keeping the focus of these errors on the patient. Confrontation by the 609445 APAXXX10.1177/0003065115609445Book essayOn the Need to Consider Retirement research-article2015

Moving Out of the Office: Removing Barriers to Access to Psychiatrists.

Our paper offers a perspective on barriers to access to psychiatric care. Research shows that access depends not simply on the total number of trained specialists but also on their kind of practice. In some large cities, some practitioners follow a small number of patients in long-term psychotherapy, a practice supported by government insurance, which places no limits on the number of sessions or treatment duration. The problem is that long-term psychotherapy, despite a rich tradition in psychiatry, is not an evidence-based treatment. This review recommends a model in which psychiatrists spend more time in consultation with primary care professionals, in acute care for patients with severe mental illness, and in briefer, more cost-effective forms of psychotherapy.

Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: Six-year follow-up of a randomized study

Objective: This study reports the six-year follow-up data of patients with borderline personality disorder (BPD) who participated in the Ullevål Personality Project (UPP), a randomized clinical study comparing outpatient individual psychotherapy (OIP) with a long-term combination programme (CP) comprising short-term day-hospital treatment followed by outpatient combined group and individual psychotherapy. Methods: For 52 patients, outcomes were evaluated after 8 months, 18 months, 3 years, and 6 years based on a wide range of clinical measures, such as symptom severity, psychosocial functioning, personality functioning, and Axis-I and II diagnoses. Results: At the six-year follow-up, patients in the CP condition reported significantly greater reduction of symptom distress and improvements in the personality functioning domains Identity Integration and Self-control compared with patients allocated to OIP. Patients in the CP also had a more favourable long-term course of psychosocial functioning. There were no differences between treatment conditions in outcomes of interpersonal functioning and self-esteem. Conclusions: Long-term psychotherapy in a combination programme seems favourable for BPD patients. In this study, patients who received combined treatment fared better on crucial parameters than patients who received individual therapy. Of particular importance are the positive effects on fundamental borderline problem areas like Identity Integration and Self-control.

The Effectiveness of Short- and Long-Term Psychodynamic Group Psychotherapy on Self-Concept: Three Years Follow-Up of a Randomized Clinical Trial

We compared differences in self-concept change across three years after short-(STG) and long-term (LTG) psychodynamic group psychotherapy, in a mixed sample of outpatients. Self-concept was assessed at baseline and three years later, using the Structural Analysis of Social Behavior Questionnaire. Vector scores Affiliation and Autonomy were primary, and the eight cluster scores–self-free, self-affirm, self-love, self-protect, self-control, self-blame, self-attack, and self-neglect–were secondary outcome measures. Within group univariate analyses showed change in LTG across three years on the vector scores Affiliation and Autonomy, while STG only changed on Autonomy. Comparisons between STG and LTG demonstrated a significantly larger improvement in Affiliation in LTG than in STG. This difference was explained by a higher improvement in the cluster scores of self-blame, self-attack, and self-neglect in LTG, dimensions that weight negatively on the Affiliation score. Patients with more serious self-neglect and harsh, punitive self-attack/self-blame may profit more in long-term than in short-term groups.

A Substance Called Food: Long-Term Psychodynamic Group Treatment for Compulsive Overeating

Obesity has proven difficult to treat. Many approaches neglect to address the deep-rooted underlying psychological issues. This paper describes a psychodynamically oriented approach to treating compulsive overeating as an addiction. Common to all addictions is a compulsion to consume a substance or engage in a behavior, a preoccupation with using behavior and rituals, and a lifestyle marked by an inability to manage the behavior and its harmful consequences. The approach represents a shift away from primarily medical models of intervention to integrated models focusing on the psychological underpinnings of obesity. Long-term psychodynamic group psychotherapy is recommended as a primary treatment.

Randomized trial on the effectiveness of long- and short-term psychotherapy on psychosocial functioning and quality of life during a 5-year follow-up

Knowledge is incomplete on whether long-term psychotherapy is more effective than short-term therapy in treating mood and anxiety disorder, when measured by improvements in psychosocial functioning and life quality. In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP), and followed up for 5 years from the start of treatment. The outcome measures comprised 4 questionnaires on psychosocial functioning, assessing global social functioning (Social Adjustment Scale (SAS-SR), sense of coherence (Sense of Coherence Scale (SOC)), perceived competence (Self-Performance Survey), dispositional optimism (Life Orientation Test (LOT)), and 1 questionnaire assessing quality of life (Life Situation Survey (LSS)). Short-term therapies improved psychosocial functioning and quality of life more than LPP during the first year. The only exceptions were LOT and perceived competence, which did not differ between SPP and LPP. Later in the follow-up, SOC and perceived competence showed significantly more improvement in LPP than in the short-term therapy groups. No direct differences between SFT and SPP were noted. Short-term therapy has consistently more short-term effects on psychosocial functioning and quality of life than LPP, whereas LPP has some additional long-term benefits on psychosocial functioning.