The usefulness of research for psychodynamic psychotherapists

– and vice versa

Rolf SandellLinköping University

1. PDT is no worse than CBT

Psychodynamic therapies vs. othersMeta-analyses of comparisons of effects sizes of active treatments (by Cohen’s d) (Luborsky et al., 2002)

Reports Meta-analyses No. of studies

Effect sizes

Svartberg & Stiles, 1991 dynamic vs. C–B 6 -.47*

dynamic vs. behavioral 5 -.10

dynamic vs. nonspecific 3 .29

Crits–Christoph, 1992 dynamic vs. nonpsychiatric 5 .32

dynamic vs. psychiatric 6 -.05

Luborsky et al., 1993 dynamic vs. other 3 .00

Luborsky et al., 1999 dynamic vs. behavioral 7 -.03

dynamic vs. cognitive 4 .02

Mean weighted effect size d

dynamic vs. other

-.0025

Author No Treatment

Minimal Alternative

Basset & Pilowsky (1985) .51 Brom et al. (1989) .20 Budman et al. (1988) .61 .00 Carroll et al. (1991) .00 DiMascio et al. (1979) .97 .00 Elkin et al. (1989) .36 .00 Fairburn et al. (1993) .00 Gallagher & Thompson (1982) -.53 Hall & Crisp (1987) .00 Hersen et al. (1984) .14 Horowitz et al. (1984) .77 Manas & Vasilopoulou (1983) .55 Marmar et al. (1988) .34 McCallum & Piper (1990) .83 McLean & Hakstian (1979) -.14 Meyer (1981) .33 .07 Pierloot & Vinck (1978) -.04 Piper et al. (1990) .52 Rosser et al. (1983) .00 .00 .00 Rounsaville et al. (1983) .00 Sloane et al. (1975) .38 .06 Sifneos et al. (1980) 2.29 Sjodin et al. (1986) .13 Thompson et al. (1987) .80 -.13 Winston et al. (1991) .93 Woody et al. (1983) .64

Unweighted overall d .71** .34* .03 Weighted overall d .55** .33* .08 *p< .01; **p< .001.

Psychodynamic brief psychotherapy(Anderson & Lambert, 1995)

Brief PDT ”outperformed alternative treatments at follow-up assessment when measures of personality were used or when

assessment took place 6 or more months posttreatment” (Anderson

& Lambert, 1995).

Effect Sizes (d) in 22 Randomized Studies of Short-Term Psychodynamic Psychotherapy (Leichsenring, Rabung & Leibing, 2004)

STPP CBT Other therapies

TAU Waiting-list

Target problems (pre-post)

1.39 1.38 1.14 0.66 0.27

Target problems (pre-fu)

1.57 1.33 1.13 0.84 NA

General psychiatric symptoms (pre-post)

0.90 1.04 0.82 (0.22) 0.12

General psychiatric symptoms (pre-fu)

0.95 0.97 0.74 (0.24) NA

Social functioning (pre-post)

0.80 0.92 1.10 (0.38) 0.21

Social functioning (pre-fu)

1.19 1.05 0.79 (0.95) NA

Between-Groups Effect Sizes (d) (Leichsenring, Rabung & Leibing, 2004)

STPP vs Other

therapies (incl. CBT)

STPP vs Waiting-list/TAU

Target problems (pre-post)

0.04 1.17*

Target problems (pre-fu)

0.23 0.94

General psychiatric symptoms (pre-post)

-0.04 0.70*

General psychiatric symptoms (pre-fu)

0.08 0.64

Social functioning (pre-post)

-0.22 0.59*

Social functioning (pre-fu)

0.02 0.87

Pre-post differences in CBT and PDT in a student clinic

(A Karlstedt, 2002; I Månsson & C Olverin, 2004)

pre-post d

Inventories KBT PDT

Beck Depression 0.69 < 0.80

Beck Anxiety 0.79 > 0.43

Quality of Life 0.39 < 0.72

Client Satisfaction 0.89 = 0.85

Cognitive Behavioral Cognitive-behavioral

Psychotherapy

Behavioral -0.12

Cognitive-behavioral

0.03 0.16

General verbal 0.15 -0.15 -0.09

Drug therapy -0.07

Combination 0.01

Tricyclics -0.07

Combination (tri) 0.05

Comparative effects sizes of treatments for depression

(Robinson, Berman & Neimeyer, 1990)

Different effects on depression?

Comparisons of STPP and CBT (Leichsenring, 2001)

All measures Depression

General psychiatric symptoms

Specific psychiatric symptoms

Social functioning

STPP = CBT

58/60 28/29 10/10 16/17 4/4

STPP < CBT

2/60 1/29 0/10 1/17 0/4

STPP > CBT

0/60 0/29 0/10 0/17 0/4

Percentages of Patients Judged as Remitted or Improved After STPP and CBT/BT (Leichsenring, 2001)

Studies Criterion of outcome

N φ Fisher z

Post assessment

Hersen, Himmelhach, & Thase, 1984

BDI + HRSD < 11

47 0.19 0.18

Thompson, Gallagher, & Steinmetz-Breckenridge, 1987

SADS-Change, RDC

91

0.17 0.17

Elkin et al., 1989 HRSD < 7 84 0.04 0.04

Shapiro et al., 1994 BDI < 9 49 0.06 0.06

Gallagher-Thompson & Steffen, 1994

SADS-Change, RDC

52 0.25 0.26

Genomsnitt 0.08 Follow-up assessment

Gallagher-Thompson, Hanley-Peterson, & Thompson, 1990

SADS-Change, RDC

74

0.13 0.13

Shea et al., 1992 LIFE-II, MDD 99 0.05 0.05

Shapiro, Rees, Barkham, & Hardy, 1995 BDI < 9 49 0.15 0.15

Gallagher-Thompson & Steffen, 1994

SADS-Change, RDC

48 0.24 0.25

Genomsnitt 0.12

Table 2. Aggregate effect sizes, confidence intervals, and probabilities under H0 for comparisons between CT and bona fide and non-bona fide treatments (Wampold, Minami, Baskin & Tierney, 2002, i en re-analys av Gloaguen et al., 1998)

Set n d+ 95% Confidence interval

p

Bonafide 10 0.16 -0.01 - 0.32 .00

Bona fide (- outlier)

9 0.03 -0.15 – 0.20 .34

Non-bona fide 11 0.49 0.28 – 0.69 .00

Are ”other therapies” really bona fide therapies?

Outcome Measures From Studies Included in a Meta-Analysis Examining the Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders (Leichsenring & Leibing, 2003)

Form of Therapy and Outcome Measure Number

of Studies

Mean d SD Median Range

Psychodynamic therapy Attrition (%) 11 15.36 12.39 14 0 – 38 Improvement effect size

Overall 15 1.46 0.73 1.29 0.34 - 2.70 Self-report measures 12 1.08 0.36 0.94 0.65 - 1.67 Observer-rated measures 12 1.79 1.07 1.90 0.34 - 4.02

Improvement effect size for specific measures of personality disorder pathology 6 1.56 0.76 1.65 0.50 - 2.40

Improvement effect size for control conditions Self-report measures 2 0.10 0.50 0.10 -0.26 - 0.45 Observer-rated measures 0

Recovery (%) 3 59 22 40 30 – 72 Cognitive behavior therapy Attrition (%) 9 16.89 10.45 15 0 – 31 Improvement effect size

Overall 10 1.00 0.48 0.99 0.34 - 2.10 Self-report measures 8 1.20 0.38 1.20 0.81 - 1.85 Observer-rated measures 8 0.87 0.71 0.70 0.19 - 2.40

Improvement effect size for control conditions Self-report measures 2 0.17 0.01 0.17 0.16 - 0.18 Observer-rated measures 3 0.51 0.39 0.40 0.19 - 0.95

Recovery (%) 1 47

Psychotherapy with personality disorder

Psychotherapy with schizofrenia”This study used meta-analytic methods to determine the effectiveness of individual psychotherapy for schizophrenic patients. …included 37 studies from various countries. … the investigation yielded seven mean effect sizes from seven different treatment comparisons. Six out of seven effect sizes were positive… Without medication, the improvement rates … ranged from –6% to 47%; when used with medication the range was from 19% to 62%. There was no difference among treatments from different theoretical orientations, indicating that psychoanalytic psychotherapy, cognitive-behavioral therapy, and non-psychodynamic supportive therapy are equally effective. …. Individual psychotherapy is a highly effective treatment for schizophrenia …” [Gottdiener, W H (2001) The benefits of individual psychotherapy for schizophrenic patients: A meta-analytic review of the psychotherapy outcome literature. Diss Abstr, 2001–95002–225; Gottdiener, W H & Haslam N (2002). The benefits of individual psychotherapy for people diagnosed with schizophrenia: A meta-analytic review. Ethical Human Sciences and Services, 4, 163-187]

Differences between techniques/schools

account for less than 1% of the outcome variance

(d = 0 – 0.2)!

Implications for psychodynamic self-esteem—and

for competitive strategies on the psychotherapy market?

2. Long-term is not necessarily better than short-term …

H. I. Howard m fl (1986)

Antal sessioner

100,0080,0060,0040,0020,00,00

Pro

cen

t "f

örb

ätt

rad

e"

100

80

60

40

20

0

"Objektivt"

vid avslutning

"Subjektivt"

under terapi

… and more frequent is not necessarily better than less

frequent

Duration and frequency interact

Post-treatment time, year

321treatment end-state

Squ

are

root

GS

I

1,4

1,2

1,0

,8

,6

,4

Sessions x w eeks

<1; <85

<1; >160

>2; <85

>2; >160

normal mean

caseness criterion

3. Money does not buy good outcome—directly

Implications for ”dosing” and ”subsidization”?

4. The therapy does not end when the therapist and the patient

stop seeing each other

Outcome is a process

Extensive relapse (78-88%) 12-18 mos. after termination in

the NIMH-TDCRP (16 sessions).

At termination…

Time, in relation to treatment

SC

L-9

0 (

GS

I) m

ean r

atin

gs

1,5

1,0

,5

0,0

psychotherapy

psychoanalysis

norm group M

1.28 norm group SD

… and three years post-treatment

Time, in relation to treatment

late after

aftersoon after

late during

during

early during

late before

before

SC

L-90

(G

SI)

mea

n ra

tings

1,5

1,0

,5

0,0

1,28 norm group SD

norm group M

Implications for follow-up interviewing/boosting?

5. Psychodynamic psychotherapy is not

a special case of psychoanalysis (or vice versa)

Therapeutic Attitudes Scales (TASC-2)

National random sample (N = 227)

Pessmism

(*)

Artistry***

Irrationality***

Self-doubt

Insight***

Neutrality***

Kindness***

Support***

Adjustment***

Me

an

Z s

core

s

1,5

1,0

,5

0,0

-,5

-1,0

-1,5

cognitive/

/behavioral (14%)

psychoanalytic

(32%)

dynamic

eclectic (33%)

cognitive

eclectic (22%)

Psychoanalysis

Treatment stages

late after

aftersoon after

late during

during

early during

late before

psya

n M

ean

SC

L-90

(G

SI)

mea

n sc

ores

1,5

1,0

,5

0,0

Cluster

psychoanalytic

caseness criterion

normal mean

Psychotherapy

Treatment stages

late after

aftersoon after

late during

during

early during

late before

SC

L-90

(G

SI)

mea

n sc

ores

1,5

1,0

,5

0,0

Clusters

cognitive/

behavioural

psychoanalytic

dynamic

eclectic

cognitive

eclectic

normal mean

caseness criterion

What doesn’t matter in psychoanalysis does so in

psychotherapy.

Training therapy

Psychoanalysis cases

Treatment stage

late after

afterearly after

late during

during

early during

GS

Isqr

t

1,5

1,0

,5

0,0

Psa <10.5 yrs

Psa >10.5 yrs

normal mean

caseness criterion

Psychotherapy cases

Treatment stage

late after

afterearly after

late during

during

early during

GS

Isqr

t

1,5

1,0

,5

0,0

Training therapy

Pst <10.5 yrs

Pst >10.5 yrs

Psa <10.5 yrs

Psa >10.5 yrs

normal mean

caseness criterion

Negative transfer from psychoanalysis to psychotherapy

– ”as-if psychoanalysis.”

Implications for clinical practice

of ”as-if psychoanalysis”?

6. Symptoms respond more easily to psychoanalysis than do social relations

T im e , in r e la t io n t o t r e a t m e n t

Soc

ial r

elat

ions

3 , 0

2 , 5

2 , 0

1 , 5

1 , 2 8 n o r m g r o u p S D

n o r m g r o u p M

T im e , in r e la t io n t o t r e a t m e n t

Sym

ptom

dis

tres

s

1 , 5

1 , 0

, 5

0 , 0

1 . 2 8 n o r m g r o u p S D

n o r m g r o u p M

7. Effects on well-being do not necessarily generalize to health

care utilization

Time, in relation to treatment

late after

aftersoon after

late during

during

early during

late before

before

SC

L-9

0 (

GS

I) m

ea

n r

atin

gs

1,5

1,0

,5

0,0

normal mean

caseness criterion

Well-being

Treatment stage

late after

aftersoon after

late during

during

early during

late before

Day

s ab

sent

from

wor

k

300

200

100

0

”Sickness” absenteeism

Treatment stage

late after

aftersoon after

late during

during

early during

late before

Day

s ab

sent

from

wor

k

300

200

100

0

Cluster

1 (37%)

2 (36%)

3 (11%)

4 (10%)

5 (6%)

Treatment stage

late after

aftersoon after

late during

during

early during

late before

Num

ber

of m

edic

al v

isits

3,0

2,5

2,0

1,5

1,0

,5

0,0

Treatment stage

late after

aftersoon after

late during

during

early during

late before

Num

ber

of m

edic

al v

isits

15

10

5

0

Clusters

1 (47%)

2 (27%)

3 (14%)

4 (9%)

5 (3%)

Implications for aspirations and goal setting—and for cost-effectiveness analyses?

8. The main source of variation is not different psychotherapies but different psychotherapists

Outcome variation between therapists

in the same form of therapy is 6-10 times larger

than the variation between

different forms of therapy (Wampold, 2001)

Therapist clusters (tutthlm2; N = 219) 71%

Treatment stages

late after

aftersoon after

late during

during

early during

late before

GS

I

2,5

2,0

1,5

1,0

,5

0,0

Clusters

1 (28%)

2 (24%)

3 (21%)

4 (11%)

5 (9%)

6 (7%)

caseness criterion

normal mean

Therapist clusters (N = 137)

Treatment stage

late after

aftersoon after

late during

during

early during

Day

s ab

sent

from

wor

k

300

200

100

0

Clusters

#1 (55%)

#2 (16%)

#3 (10%)

#4 (9%)

#5 (6%)

#6 (4%)

#7 (1%)

Implications for training, evidence-basing, and

quality assurance?

”The dark continent” in psychotherapy (research)

”Vice versa”: The usefulness of psychodynamic psychotherapists

for research

Participation in research