Horst Kächele

Short or Long Term Psychoanalytic Therapies

Moscow 2008

Time for Psychotherapy

How much time (sessions / weeks) is provided in experimental treatment research and

How much time is provided for whom in which form of treatment in naturalistic settings ?

and

Does it make a difference ?

Duration of Experimental Randomized Controlled Treatment Studies

based on Grawe et al. 1994

Cognitive-Behavioral Therapies – 429 Studies, mean length 11,2 sessions– 434 Studies, mean. length 7, 9 weeks

Humanistic Therapies – 70 Studies, mean. length 16,1 sessions – 76 Studies, mean. length 11, 6 weeks

Psychodynamic Therapies – 82 Studies, mean. length 27,6 sessions– 80 Studies, mean. length 30,7 weeks

Psychoanalytic Therapies in RCTs (Leichsenring 2004)

# Affective disorders (ICD-10 F3)

# Anxiety disorders (ICD-10 F40-42)

# Adaptive disorders (ICD-10 F43)

# Dissociative, somatoforme disorders (ICD-10 F44, F45, F48)

# Eating disorders (ICD-10 F50)

# Psychic and social factoren in somatic disorders (ICD-10 F54)

# Personality- and behavioral disorders (ICD-10 F6)

# Dependency (ICD-10 F1, F55)

Consumer Reports Study 1

• US-Survey on satisfaction with treatment

• Kind of therapy

• Kind of therapist

• Problems leading to therapy

• Duration and frequency

• Emotional state before and after therapy

• Improvements in which part of life

• Satisfaction with treatment

• Kotkin, M., C. Daviet, et al. (1996). "The Consumer Reports Mental Health Survey."

American Psychologist 51: 1080-1082.

•

Consumer Reports Study 2

• Scales values from 0 to 100• A) Special improvement• B) Satisfaction with therapist• C) Global improvement• Total score feasible between 0 - 300• Main finding:

• Total scores correlates with duration of treatment

• ( Sample size N= 2.846)

Consumer Reports Study 3

German Study on Effectiveness of Psychotherapy and Patients´

Satisfaction I

• Hartmann & Zepf (Saarbruecken) perform another replication of the CR Study using the translated CR questionaire and ADVERTISING the study through a Consumer Journal

• Hartmann, S. and S. Zepf (2003)• Effectiveness of Psychotherapy - A Replication of the Consumer-Reports-Study. • Psychotherapy Research 13: 235-242.•

German CR Study II

Effectiveness & Treatment Modality

150

200

250

300

Improvement Score

PA PP BT CCT Modality of Psychotherapy

244 237 236

223

German CR Study III

Duration and Effectiveness

German CR Study IV

Duration more than two years

• Psychoanalytic Therapy 74%• Psychodynamic Therapy 50%• Client-Centered Therapy 42%• Cognitive-Behavioral Therapy 29%

German CR Study V

Findings

• Clear cut influence of duration on consumer rated outcome

• The first significant improvement of effectiveness after 7 months, the second after one year, and a highly significant improvement after two years.

• Methodical problems reside in sampling

IPTAR Study of the Effectiveness of Psychoanalytic Psychotherapy

Aims1. What is the influence of duration on effectiveness2. What is the influence of frequency on effectiveness 3. What is the influence of duration and frequency on the therapeutic alliance4. Is there an interaction between clinical syndrome and duration, frequency and effectiveness

Sample: Patients of the IPTAR Treatment Center New YorkMethod: ConsumerReports Questionaire

Return rate: from 240 distributed questionaires (only) 99 were returned (41% rate of participation):

• IPTAR

• Sample and Method

IPTAR

Duration and Effectiveness

IPTAR

Frequency and Effectiveness

Berlin Jungian Psychoanalysis Study ICharacteristics of follow-up sample

Follow-up sample(n=111)

Mean(SD)

Age at follow-up,1994 (yrs)

44.5(4.8)

Age at start oftreatment (yrs.)

35.0(8.8)

Age at the end oftreatment (yrs)

37.0(8.0)

Time of follow-up(yrs)

5.8(0.79)

Treatment length(0.3-8.3 yrs)

2.9(1.7)

Number of therapysessions (range 15-399)

161.9(94.9)

Berlin Jungian Study Duration and outcome

(Global improvement based on three scales)

The JAMA Meta-Analysis

• Leichsenring, F. and S. Rabung (2008). • Effectiveness of long-term psychodynamic

psychotherapy. A meta-analysis.• JAMA, October 1, 2008, Vol 300, No. 13.•

Results According to comparative analyses of controlled trials, LTPP showed signifi- cantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. With regard to overall effectiveness, a between-group effect size of 1.8 (95% confidence interval [CI], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups (P = .002). According to subgroup analyses, LTPP yielded significant, large, and stable within-group effect sizes across various and particularly complex mental disorders (range, 0.78-1.98).

Conclusions There is evidence that LTPP is an effective treatment for complex mental disorders. Further research should address the outcome of LTPP in specific

mental disorders and should include cost-effectiveness analyses.

Structural Change

How can we measure „structural change“?

What is the difference between symptomatic and structural change?

Scales of Psychological Capacities (Wallerstein 1991)

Heidelberg Structural Change Scale (Rudolf et al. 2000)

Adult Attachment Interview (Main 1989)

Adult Attachment Interview

• AAI measures mental representations with respect to present status of attachment.

• Levy, K. N., K. B. Meehan, et al. (2006). • Change in attachment patterns and reflective function in a

randomized control trial of Transference-Focused Psychotherapy for borderline personality disorder.

• J Con Clin Psychol 74: 1027-1040.

•

The German DPV-Follow-Up Study

• Leuzinger-Bohleber M, Stuhr U, Rüger B, Beutel M (2003)

• How to study the quality of psychoanalytic treatments and their long term effects on patients well-being. A representative multiperspective follow-up study.

• Int J Psychoanal 84: 263-290

German DPV-Follow-Up Study

• In the sample of 400 analytic patents• Length of treatment around 4 years• No difference between low frequency (1-2) and high frequency

(3-4) in psychometric data at follow-up (6 years)• The authors claim:• if the indication is made properly than both forms of

treatment are successful.

Differences between psychoanalyses and long term analytic psychotherapies

# Both forms of treatment lead to long time stable results in the majority of patients, if the indication was properly done:

# self reflection and the internalization of the analyst were more comprehensive in analytic patients , the evaluation of achieved outcomes more differentiated, and the development of creative ressouirces more innovative.

Leuzinger-Bohleber M, Target M (Eds) (2002) Outcomes of Psychoanalytic Treatment Perspectives for Therapists and Researchers. Whurr Publishers,, London and Philadelphia,

Clinical Prototype-Formation

Capacity for relationship

Capacity to work - Creativity

Self reflection

(2002, S.130)

The Eight Clinical Prototypes

Type 1: „well done... The really good ones“

Type 2: succesful, but why,?..the unreflecting successful ones

Type 3: with success and little capicity for reflection, but socially well integrated...“

Type 4: the tragic ones, that were able to accept their lot „

Type 5: „..professionally successful and creativ, but still alone...“

Type 6: „successful within limits in their creativity and capacity to work but with clear limits...“

Type 7: „...therapy didn´ t do any good.. “

Type 8: „ the severly traumatized people“

Clusteranalytic Identification of

Sub-groups

Sub-group 1: the therapeutically successful with focus on satisfaction with health, but with a common suffering from sexuality

Sub-group 2: the therapeutically successful with focus on diffuse satisfaction

Sub-group 3: the still suffering, that are only satisfied on the average

Sub-group 4: the therapeutically successful with focus on financial satisfaction

Sub-group 5: the totally satisfied

Sub-group 6: the still suffering unsatisfied

Sub-group 7: the extrem group of less successful of all

Stuhr et al. (2002, p.154)

Measuring Structural Change with Wallerstein´s Scale of Psychological Capacities The Munich

Psychotherapy Study:

Huber D, Klug G (2003) Contributions to the measurement of mode-specific effects in long-term psychoanalytic therapy. In: Richardson P, Kächele H, Renlund C (Eds) Research on Psychoanalytic Psychotherapy with Adults. London, Karnac

1. Psychoanalysis

• 3 x weekly• couch• > 240 sessions

2. Psychodynamic Psychotherapy

• 1 x weekly• sitting• 80-120 sessions

3. Behavior-Therapy

• 1 x weekly• sitting• 25-80 sessions

Groups

Correlations of change parameters with duration (month) and dose (total session numbers)

• No final data analysis available, CAVE so far:

• Scales of Psychological Capacities: • Pre -> corr. with duration = .33

• BSS socialcomm. Pre -> corr. with dose = .37

• All other change parameters do not correlate at no time point with either duration or nor dose

The Heidelberg-Berlin Study Change of Structure Scale

Grande T, Rudolf G, Oberbracht C, Jakobsen T, Keller W (2003) Investigating structural change in the process and outcome of psychoanalytic treatment - The Heidelberg-Berlin Study. In: Richardson P, Kächele H, Renlund C (Hrsg) Research on Psychoanalytic Psychotherapy with Adults. London, p. 35-62

A Swedish point of view:

Symptomatic change indicates structural change!!!!

Sandell, R. (2005)Structural change and its assessment. Experiences from the Stockholm Outcome or Psychoanalysis and Psychotherapy Project (STOPPP). In P. Giampieri-Deutsch Psychoanalysis as an empirical, interdisciplinary science. Collected Papers on Contemporary Psychoanalytic Research. Vienna, Austrian Academy of Sciences Press, pp 269-284.

The Stockholm Outcome of Psychotherapy and Psychoanalysis

(STOPP) Study

STOPP SCL-90 Global Severity Index (GSI)

Therapists´ Attitude

• Sandell R, Lazar A, Grant J, Carlson J, Schubert J, Broberg J (2007)

• Therapists' attitudes and patient outcomes: II Therapist attitudes influence change during treatment.

• Psychother Res 17: 201-211

STOPP

Therapists´ factors

Individual therapists

Treatment stages

late afteraftersoon afterlate duringduringearly during

SCL-90 (GSI) scores

3,5

3,0

2,5

2,0

1,5

1,0

,5

0,0

Treatment result trajectories of the General Symptom Index among therapists in the STOPP-Project.

Individual trajectories of 219 therapists

T r e a tm e n t s ta g e s

late afteraftersoon afterlate duringduringearly duringlate before

SCL-90 (GSI) mean scores

3 ,0

2 ,5

2 ,0

1 ,5

1 ,0

,5

0 ,0

# 1 ( 3 1 % )

# 2 ( 2 7 % )

# 3 ( 2 7 % )

# 4 ( 1 0 % )

# 5 ( 3 % )

# 6 ( 3 % )

n o r m a l m e a n

c a s e n e s s c r it e r io n

Treatment result trajectories of the General Symptom Index among therapists in the STOPP:

Latent class model.

T r e a t m e n t s t a g e s

late afteraftersoon afterlate duringduringearly duringlate beforebefore

SCL-90 (GSI) mean scores

3 , 0

2 , 5

2 , 0

1 , 5

1 , 0

, 5

0 , 0

c a s e n e s s c r i t e r i o n

n o r m a l m e a n

Treatment results: trajectories of the General Symptom Index among therapists in the STOPPP.

Mean trajectory

Norcross & Lambert, 2006

5,0%

7,0%

10,0%

8,0%

40,0%

30,0%

pxtxrxt

teknik

relation

terapeut

???

patient

ConsequencesInteraction of therapist style and treatment intensity ?

Should treatment intensity influence therapist style ?

Answers open for discussion !!!!!!

Frequency as battle ground

• „on the one hand, the frequency of sessions is viewed as a variable dependent on the optimal combination of structuring, confrontation, and assimilation, but on the other hand, once settled it takes on the character of an independent variable, that is it becomes part of the setting and an object on which conflicts in the relationship can crystallize“

• (Thomä & Kächele Tom 1)

– Sovremenny psikhoanaliz Tom 1. Teoria.

Progress, Moskva 1997

– Sovremenny psikhoanaliz. Tom 2. Praktika.

Progress, Moskva 1997

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