effectiveness study article on psychodynamic psychotherapy

7/30/2019 Effectiveness Study Article on psychodynamic psychotherapy

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10.1177/1049731505281373R ES EA RC HO NS OC IA LW OR KP RAC TI CE Ro se bo ro ug h/ PS YC HO DY NA MI CP SY CH OTH ER AP Y

Psychodynamic Psychotherapy:An Effectiveness Study

David J. RoseboroughThe College of Saint Catherine and The University of Saint Thomas

Objective: Both the National Institute of Mental Health and the American Psychological Association have called uponpsychodynamic practitioners to start demonstrating their outcomes. Thiseffectiveness study attempted to beginto answer these calls. Method: The study was a secondary analysis of data from a multidisciplinary, psychodynamicmental health clinic. It useda single-group,within-subjectslongitudinal design.The psychometricallyvalidated Out-come Questionnaire was used as a measure of change. A linear mixed and random effects model wasused to analyzethedata. Theaims of this study were (a) to look at whether subjects improve and (b)if so,at what variables moderateoutcome. Results: Findings suggest that psychodynamic treatment, provided within this practice configuration, iseffective over time, producing moderateeffect sizes, and points to the particular importance of the first three months.Conclusions: Findings suggest a common course of recovery, with some between-group variability.

Keywords: psychodynamic; psychoanalytic; intervention research; outcome; effectiveness; efficacy; randomized

clinical trial

Mostresearch regardingpsychotherapyoutcomes is donein highly controlled settings. It uses structured,manualized treatments applied to people with a singlepsychiatric diagnosis. Although strong in design (i.e.,providing strong internal validity), questions have beenraised about the applicability of the findings from theseefficacy studies to real-life clinical settings. This is a con-cern for many clinicians in that the majority of potentialresearch subjects in such efficacy studies, especiallythose with more than one diagnosis, are often screenedout up front (Nathan, Stuart, & Dorn, 2000). These stud-ies have, to date, most often evaluated the outcomes of cognitive-behavioral (i.e., cognitive behavioral therapy)interventions, as can be seen in a review of the AmericanPsychological Associations (APA) Division 12 listing of empirically supported treatments, of which only a few arepsychodynamic in nature (APA, 1993).

The National Institute of Mental Health (Explor-atory/developmental grants for psychosocial treatmentresearch, 1993) and others (APA, 1993; Gabbard,Gunderson, & Fonagy, 2002) have lamented the lack of empirical outcome data provided by psychodynamictherapists and have called for such practitioners to startdemonstrating their outcomes. Gabbard, Gunderson, andFonagy (2002) wrote recently about the threat posed todynamic therapy by not demonstrating such outcomes:Psychoanalytic psychotherapy is at risk of being sacri-ficed if scientific methods cannot be developed that willfurther test itspractitionersclaimsof efficacy (p. 505).

This study was an effectivenessstudy:using a researchdesign with fewer controls, done in the field, to beginanswering this call. It looked at the outcomes of psychodynamic psychotherapy as it is actually practiced:within an agency setting and with different groups of cli-ents. It looked at how effective psychodynamic psycho-therapy is and at what its change process looks like.

Specific aims of thestudy:Thestudy asked the follow-ing questions.

Do clients receiving this type of treatment make significant im-provement over time?

If so, what variables appear to moderate its outcome?

Effectiveness research in this area has been, to date,quite limited. In the mid-1990s, Consumer Reports pub-lished a study based on client self-report. That study in-volved thousands of people self-reporting on their satis-

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Authors Note: This article is adapted from the authors doctoral dissertation

by the same title. I would like to express my gratitude to both Bi ll Bradshaw,Ph.D., who advised this dissertation and to the people at Hamm Clinic whoreviewed and made a significant contributions to this article: James Jordan,M.D.; Jim Theisen, Ph.D., L.P.; Tyson Burke, B.A.; and Rachel Richardson,LICSW. Correspondence may be addressed to David J. Roseborough, Ph.D.,College of St. Catherine and University of St. Thomas School of Social Work,LOR 406, University of St. Thomas, 2115 Summit Avenue, St. Paul, MN,55105, or via e-mail using [email protected].

Research on Social Work Practice, Vol. 15 No. x, Month 2005 1-DOI: 10.1177/1049731505281373 2005 Sage Publications


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faction with their own psychotherapy but did not look atsymptom change per se. In fact, its author (Seligman,1995) called for the next research in this area to look be-yond such self-report and to usemore empiricalmeasuresof symptom change. This study attemptedtodo just that.

Psychodynamic Psychotherapy Evaluation

Psychodynamic psychotherapy is one of the mostcommonly practicedforms of therapy (Anderson& Lam-bert, 1995; Doidge, 1999; Gunderson & Gabbard, 1999;Svartberg & Stiles, 1991; Vaughan et al., 2000) and yetoneof the least researched. Despite itsbeing widelyprac-ticed, this form of therapy has historically avoided evalu-ation (Doidge, 1999; Gabbard, Gunderson, & Fonagy,2002; Sandell, Bloomberg, Lazar, & Carlsson, 2000).Dynamic practitioners have historically claimed efficacyfor their treatments by referring to case studies (i.e.,Wallersteins Forty-two lives in treatment: A study in psy-choanalysis and psychotherapy in 1986), often pointingto changes observed exclusively from the analysts per-spective. Others have asserted that dynamic therapysoutcomes are beyond measurement (i.e., involving inter-nal, personality or structural change not easily or at allable to be quantified). Still others have called their prac-tice an art more than a science and thus not open to empir-ical evaluation (Stone, 1997). Doidge puts the sentimentof many of hiscolleagues concisely: We reject empiricaloutcome research (p. 674).

This historic stance, however, is gradually changing,with psychoanalytic leaders themselves calling for moreempirical research. Freedman, Hoffenberg, Vorus, andFrosch (1999) note, Psychoanalysis finds itself not in asituation of crisis, but surely in one of reorganization (p.741). Kernberg (1991) raises the concern that by havingavoided research, our psychoanalytic institutes are char-acterized by an atmosphere of indoctrination rather thanof free scientific exploration (p. 55). By this he meansthat psychoanalysis is at risk of being taught as an ideol-ogy, as a closed system not open to the challenges or cor-rectives scientific inquiry might bring. In so doing, he isechoing an older criticism of psychoanalysis brought

originally by philosopher of science Karl Popper, whorejected psychoanalysis as a closed or circular system notopen to the scrutiny of science (Popper, 1963).

Kernberg also calls for psychoanalytic schools not tobe free-standing but to join with universities in the spiritof holding psychoanalytic concepts up to scientific scru-tiny (p. 57-58) and points to the risk of the fields stagna-tionby failing to doso (p. 61). He ultimately hopes for thefield to become more scientific: to test and to ground its

assertions in science (p. 61). He is not alone in this desire.Other leaders withinpsychoanalysis such as Gabbard andGunderson (1999) are acknowledging the need now toevaluate its outcomes empirically (see also Barber &Lane, 1995; Doidge, 1999; Sandell et al., 2000).

METHOD

Sample

Participants ( n = 164) were all adult outpatients inpsychodynamic psychotherapy, as offered by this clinic.Thirty different treating therapists were represented inthis sample. Treating therapists were primarily master-level social workers and psychologists. Most subjectswere seen for just longer than a year, averaging 64 ses-sions, although with a large degree of variation ( SD =44.6). The total number of sessions ranged between 4 and237 sessions. Most subjects were seen somewherebetween 20 and 100 sessions, usually with one time aweek as the standard of care. Approximately a third(31%) of these clients reported a planned termination,whereas 44% of these clients simply withdrew. Sixteenpercent ended because of their therapists internship end-ing. The rest ended for other reasons, including a groupending, being referred out, or for unidentified reasons.

Clients ranged in age between 20 and 83. The meanage for a client in this sample was 38 ( SD = 12.00). Themajority of clients were female (60%). In keeping withnational samples, the majority were on medication atsome point during their therapy. Total, 68% used medica-tion during their therapy, whereas 32% did not. This is ahigher percentage than the national average of 62%(Olfson, Marcus, Druss, & Pincus, 2002) and may beaccounted for by the clinic having psychiatrists on staff,in house, and by its strongly interdisciplinary model.

Just under one half (45%) of subjects had one or morecomorbid disorders, whereas just more than half (51%)were diagnosed with a singlepresenting diagnosis (4%of this data wasmissing). Thevast majority of these diagno-ses were Axis I diagnoses (i.e., clinical syndromes), with

only a small number of people presenting with an adjust-ment disorder or V-Code ( n = 19) or personality disorder(n = 3) as primary diagnoses. Fourteen subjects (8.5%)presented, although, with a personality disorder as part of their overall diagnosis. Initial presenting diagnoses canbe broken down according to major depression ( n = 49),dysthymia ( n = 43), mood-other ( n = 19), anxiety ( n =22),adjustment disorders or V-codes ( n = 19), and other (

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consisting of alcohol dependence, eating disorders, etc.,with n = 6).

Clientsinitial presentations were also in keeping withnational norms for adult outpatients entering mentalhealth settings (see comparison table below). The pre-senting scores were as follows.

Treatment Conditions

Setting . Hamm Memorial Psychiatric Clinic is anadult, outpatient mental health center located in St. Paul,Minnesota. It is a multidisciplinary clinic, employingeight social workers, fivepsychologists, and threepsychi-atrists. The clinic provides both psychodynamic psycho-therapy as well as psychiatric consultation, with or with-outmedication management. It does not offer medicationmanagement apart from psychotherapy. That is, all cli-ents receiving medication at the clinic are currently cli-ents in therapy at the clinic. Services are offered along a

sliding scale. Theclinic also provides clinical training forgraduate level psychologists, psychiatrists, and socialworkers as an integral part of the clinics practice struc-ture (i.e., its service and training milieu). It also providescontinuing educationin psychodynamic topics for mentalhealth practi t ioners already in practice in themetropolitan area.

Procedures

Staff therapists consist of graduate level psychologistsand social workers, all of whom are educated at either a

masters or doctoral level and all of whom have signifi-cant training and experience in this relationship-focusedmodel of psychotherapy, including continuing trainingand education through the clinic itself. Many are gradu-ates of the clinics training program and several teach thecohort of 8 to 10 interns and residents within the clinic atany given time, in addition to their practice.Treatingther-apists are Caucasian ( n = 10), Hispanic ( n = 2), and Afri-can American ( n = 1). Most of the practitioners are

women ( n = 11), whereas five are men. The clinicemploys three psychiatrists, who are trained as psycho-therapists. Clinic administrators are similarly cliniciansand carry a case load as part of their clinic duties. Theclinics work is strongly cross-disciplinary. Clients areconsidered clinic clients. Social workers, psychologists,and psychiatrists have input into cases during weekly

group supervision.Practitioners use an approach that is generally consis-tent with the principles described by Gabbard (2000) inhis book Psychodynamic Psychiatry . This model is basedon both a descriptive (i.e., DSM-IV) and relational diag-nosis (understood as the impact of both past and presentrelationships), the fostering of a strong working alliance,the use of the therapeutic experience as a corrective one,theexplorationof transference, and thepositiveuseof thetherapy relationship in general. This therapeutic relation-ship is seen as something that is gradually internalized bythe client. It occurs along a supportive-expressive contin-uum, and careful attention is given to both resistance andto the client-therapist interaction (Gunderson& Gabbard,1999). The clinic draws heavily on both (a) attachmentand (b) object relations as its core theoretical underpin-nings. The clinic estimates the cost of this intervention at$2,645.00 per course of therapy (this estimate assumes a23 session intervention, the clinics average, at a cost of $115.00 per session).

Outcome Measure

Measure . The study used the Outcome Questionnaire(OQ-45.2) (Lambert, Gregersen, Brulingame, & Marush,2004; Lambert et al., 1996). The OQ is a 45 item client-administered questionnaire developed specifically tomeasure outcomes relevant to dynamic therapy. It uses a5-point scale. The OQ provides both an overall score aswell as three subscales or domain scores: (a) symptomdistress (how the person feels inside, the level of distresssymptoms cause), (b) interpersonal relations (how theperson gets along with others), and (c) social role (howtheperson functions in terms of important life tasks). Theinstrument has been normed on several community sam-

ples, including the psychiatrically well, clients of employee assistance programs, clients in outpatient men-tal health therapy, and with psychiatric inpatients. It hasalso been testedacrossgender, race, andwith various eth-nicities. It includes a cut-off score that differentiates nor-malcommunitysamples from symptomatic and impairedclinical samples as well as a way to calculate clinicallysignificant change (i.e., versus a full recovery) on all fourscales. The OQ has been tested for both internal

Roseborough / PSYCHODYNAMIC PSYCHOTHERAPY 3

Table 1:OQ Sample Scores in Relation to National Norms

Clinics Mean National Mean

OQ total 82.09 83.09OQ symptom distress 47.62 49.40OQ interpersonal relationship 20.09 19.68OQ social role 14.46 14.01

NOTE: OQ = Outcome Questionnaire.


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consistency and for test-retest reliability (see Lambert,Finch, & Maruish, 1999; Mueller, Lambert , &Burlingame, 1998).

Data Analysis

Thestatistical package SPSS 12.0 wasused to perform

the inferential statistical analyses. A mixed effects modelwas chosen largely because of thenature of thedata itself.For instance, repeated measures ANOVA could not beperformed because of the amount of missing data in ear -lier cliniccases.Although most cases included a baseline,the other data points were spread out during the course of 3 or more years of therapy. There was a high degree of attrition: 127 cases had a baseline, 66 had a 3-monthscore, 64 had a 6-month score, 43 had a 9-month score,and only 35 had a score at 12 months. From 15 to 24months, the number of respondents ranged around thelow 20s at each 3-month interval, and only 7 respondentshad data points at 3 or more years). Because of this degreeof attrition (i.e., drop off), the decision was made to ana-lyze a years worth of data, which would be in keepingwith existing studies (i.e., Asay, Lambert, Gregersen, &Goates, 2002; Kopta, Howard, Lowry, & Beutler, 1994)and offer a good basis for comparisons with existingliterature.

The mixed effects model used is a regression-likeapproach. This approach allows the researcher to create atrend line, which shows both (a) the direction and (b) thestatistical significance of a change. It also allows bothwithinand between group comparisons. Themodel looksfor trends or changes over time, by plotting residuals. Asin regression, it assumes that a random or nonsignificantline is a straight and horizontal one. Time is seen as afixed variable and each subject at each time point (in thiscase, each 3-month interval) varies randomly.Nonrandom changes move this line up or down to signifi-cant or nonsignificant degrees. Treating subjects as ran-dom effects also saves a number of degrees of freedomand allows for later between group comparisons.

Power Analysis

A power analysis was conducted using software fromSSI.com (Congdon, 2001) called Optimal Design,which provides a power analysis uniquely suited to (a) amixed model, which uses both (b) repeated measures and(c) linear, quadratic, or cubic data. This model does so byfactoring in the duration of the study, the expected effectsize, the frequency and spacing of observations, the num-ber of subjects, and the expected degree of variation

across persons (Raudenbush & Xiao-Feng, 2001). It usesallof this information to createa multidimensional poweranalysis (relying on vectors and matrices vs. a singlevalue the way a unidimensional power analysis might inthecase of ANOVA). Using this software and itsunderly-ing model (see Raudenbush & Xiao-Feng, 2001), it wasdetermined that the 164 people in this study would pro-

vide a 72% probability of correctly identifying signifi-cant versus nonsignificant findings (a power or d value of .72).

RESULTS

Research Question 1: Will people show statisticallysignificant change between beginning and ending thistreatment?

Effect Size

The overall effect size for this treatment was found tobe moderate. The effect size for 1 year of treatment wascalculated by subtracting the score at 1 year (OQTOT5)as the intervention mean from the baseline OQ(OQTOT1) and dividing that number by the baseline(OQTOT1) standard deviation. This yielded a d index of .41. This value is squarely in the middle of a mediumeffect size, as defined by Lipsey (1990) in a review of more than 6,700 studies on treatment effectivenessresearch.Similarly, an effect size wascalculated using thesame approach for the first 3 months of treatment, whichhad appeared as the only 3-month interval during whichstatistically significant change happened as part of, ordefining, a unique treatmentperiod. This analysis yieldedan effect size of .44. This treatment effect was also thusmoderate. The treatment effect was found to be, asexpected, moderate or medium. Theactual strength of theeffect, however (.4) was less than anticipated and some-what lower than the range in the existing literature, inwhich estimates have ranged from .6 to 2.02. Effect sizesfor each of the subscales averaged .33.

OQ Total Score

Respondents showed statistically significant changeon the OQ total score (OQTOT) between beginning andending this treatment. The mixed effects model looked atOQ total scores during the course of a year of treatment.OQ total scores were defined as the dependent variable.Time was identified as a fixed factor. A high degree of correlation between the testing periods was assumed and

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was factored into the model, as Lambert et al. (1996)point to strong correlation coefficients between weeks onthe OQ during a 10-week period ranging from .66 to .82(p. 10). This assumption was also verified for this data setby running correlations between each of the OQTOTscores at each 3-month interval, which revealed correla -tions between OQTOT scores ranging from .312 to .875

(with most in the .5 to .7 range). The model constructed assuch produced an F valueof 4.67 (210.124), significant at p < .01, identifying OQ scores as changing significantlyover timein this case, during the course of a year. Thenature of this change (in OQ total scores during a year)can be graphed as follows.

Change on this overall score (OQTOT) produced aneffect size of .41.

OQ Symptom Distress Subscore

Statistically significant change was also made duringthe course of a year on the symptom distress subscale,which produced an F value of 4.1 (211.5), significant at

effectiveness study article on psychodynamic psychotherapy

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