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"Psychoanalytic Therapy methods."
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Childhood trauma and differential response to long-term psychoanalytic versus cognitive–behavioural therapy for chronic depression in adults
Childhood trauma is a major risk factor for chronic depression. It has been suggested that adults with chronic depression who have experienced childhood trauma may require long-term treatment owing to a breakdown of basic trust and related difficulties in developing a productive therapeutic relationship.
As empirical studies have been preliminary and scarce, we studied the effects of psychoanalytic therapy (PAT) versus cognitive-behavioural therapy (CBT) for chronic depression in adults with a history of childhood trauma. In this subgroup, we expected a greater symptom reduction in PAT compared with CBT.
In a large trial of long-term psychotherapies for chronic depression (LAC-Study; Clinical Trial Register ISRCTN91956346), 210 adults received open-ended CBT or PAT in an out-patient setting and were examined yearly over 5 years on the Beck Depression Inventory - II (BDI-II). Based on a linear mixed model approach, we tested participant-reported childhood trauma based on the Childhood Trauma Questionnaire (CTQ) as a predictor and moderator of treatment outcome. CTQ subscales were examined exploratively.
Depressive symptoms decreased over time (
= -4.55, s.e. = 0.90, 95% CI -6.32 to -2.81,
= -5.08;
< 0.001). A significant three-way interaction between childhood trauma, time and therapy group (
= -0.05, s.e. = 0.02, 95% CI -0.09 to -0.01,
= -2.42;
= 0.016) indicated that participants with childhood trauma profited especially well from PATs.
Our results indicate differential benefits from PAT compared with CBT among adults with chronic depression and a history of childhood trauma. The results have important implications for differential indication and policy.
Journal Article
What contributes to good outcomes? The perspective of young people on short-term psychoanalytic psychotherapy for depressed adolescents
Depression is the fourth leading cause of adolescent illness and disability worldwide. A growing evidence base demonstrates that Short Term Psychoanalytic Psychotherapy [STPP] is an efficacious treatment for moderate to severe adolescent depression. However, with research in its infancy, key factors contributing to efficacy are unknown. Service users’ lived experiences provide valuable insight in this area. This study aimed to elucidate what adolescents value in treatment by inductively exploring lived experiences of STPP. Five adolescents with the largest reduction in depressive symptoms scores between baseline and end of treatment, who had taken part in a large-scale randomized controlled trial, were sampled. In-depth interviews carried out soon after the end of therapy were analysed using Interpretative Phenomenological Analysis. Three superordinate themes were identified: “Therapy as a Transformational Process”, “Explorative and Exposing: The Therapeutic Space” and “Being Heard and Working Together: The Therapeutic Relationship”. Adolescents valued a process of collaborative exploration with the therapist which when it was achieved was felt to facilitate a deep-rooted transformation in self-perception. Additionally, they described how an adjustment was needed to the particular frame of a psychoanalytic therapy. However, not all participants with a good treatment outcome experienced therapy in this way, suggesting a potential gap between the quantitative assessment of outcomes, and the way young people experience and understand the change process. Clinical implications and directions for research are discussed.
Journal Article
A randomized waitlist-controlled trial comparing detached mindfulness and cognitive restructuring in obsessive-compulsive disorder
Whereas research has demonstrated the efficacy of cognitive restructuring (CR) for obsessive-compulsive disorder (OCD), little is known about the efficacy of specific metacognitive interventions such as detached mindfulness (DM). Therefore, this study compared the efficacy of CR and DM as stand-alone interventions.
We conducted a randomized waitlist-controlled trial. n = 43 participants were randomly assigned to either DM or CR. Out of those participants, n = 21 participants had been previously assigned to a two-week waitlist condition.
In both conditions, treatment comprised four double sessions within two weeks. Assessment took place at baseline (Pre1), after treatment (Post) and four weeks after the end of treatment (FU). There was a second baseline assessment (Pre2) in the waitlist group. Independent evaluators were blinded concerning the active condition. Adherence and competence ratings for the two therapists were obtained from an independent rater.
40 patients completed the treatment. Two patients dropped out because of exacerbated depression. There were no further adverse events. Both CR and DM were shown to be superior to waitlist and equally effective at reducing OCD symptoms from pre to post assessment as measured with the Y-BOCS (CR: d = 1.67, DM: d = 1.55). In each of the two treatment conditions, eight patients (40%) exhibited a clinical significant change at post assessment.
The results of this clinical trial suggest the potential efficacy of DM as a stand-alone intervention for OCD, however, our findings need to be interpreted with caution. Results indicate that both CR and DM should be considered as possible alternative treatments for OCD, whereas the working mechanisms of DM have yet to be elucidated.
Journal Article
Micro-trauma : a psychoanalytic understanding of cumulative psychic injury
\"Micro-trauma: A psychoanalytic understanding of cumulative psychic injury explores the \"micro-traumatic\" or small, subtle psychic hurts that build up to undermine a person's sense of self-worth, skewing his or her character and compromising his or her relatedness to others. These injuries amount to what has been previously called \"cumulative\" or \"relational trauma.\" Until now, psychoanalysis has explained such negative influences in broad strokes, using general concepts like psychosexual urges, narcissistic needs, and separation-individuation aims, among others. Taking a fresh approach, Margaret Crastnopol identifies certain specific patterns of injurious relating that cause damage in predictable ways; she shows how these destructive processes can be identified, stopped in their tracks, and replaced by a healthier way of functioning. Seven different types of micro-trauma, all largely hidden in plain sight, are described in detail, and many others are discussed more briefly. Three of these micro-traumas--\"psychic airbrushing and excessive niceness,\" \"uneasy intimacy,\" and \"connoisseurship gone awry\"--have a predominantly positive emotional tone, while the other four--\"unkind cutting back,\" \"unbridled indignation,\" \"chronic entrenchment,\" and \"little murders\"--have a distinctly negative one. Margaret Crastnopol shows how these toxic processes may take place within a dyadic relationship, a family group, or a social clique, with the consequence of causing collateral psychic damage all around. Using illustrations drawn from psychoanalytic treatment, literary fiction, and everyday life, Micro-trauma : A psychoanalytic understanding of cumulative psychic injury outlines how each micro-traumatic pattern develops and manifests itself, and how it wreaks its damage\"--Provided by publisher.
BOOK
Implementing Panic-Focused Psychodynamic Psychotherapy into Clinical Practice
Objective:
To determine the effectiveness of manualized panic-focused psychodynamic psychotherapy (PFPP) in routine care in Germany.
Method:
German psychoanalysts were trained according to the PFPP manual. Fifty-four consecutive outpatients with panic disorder (with or without agoraphobia) were randomly assigned in a 2:1 ratio to PFPP or cognitive-behavioural therapy (CBT) plus exposure therapy. Subjects (female 57.4%; mean age 36.2 years) had high rates of psychiatric (68.5%) and somatic (64.8%) comorbidity, and previous psychiatric treatments (57.4%). Assessments were performed pre- and posttreatment and at 6-month follow-up. The primary outcome measure was the Panic Disorder Severity Scale.
Results:
Both treatments were highly effective. In patients randomized to PFPP, remission was achieved in 44.4% at termination and by 50% at follow-up (CBT 61.1 % and 55.6%, respectively). No significant differences were found. Emotional awareness, a posited moderator of good outcome in psychotherapies, was significantly higher in the CBT group at baseline. It was found to be a strong moderator of treatment effectiveness in both treatments. After adjusting for initial Levels of Emotional Awareness Scale (LEAS) scores, effect sizes (ESs) for the primary outcome were Cohen d = 1.28, from pre- to posttreatment, and d = 1.03, from pretreatment to follow-up, for PFPP, and d = 1.81 and 1.28 for CBT, respectively.
Conclusions:
PFPP was implemented effectively into clinical practice by psychoanalysts in the community in a sample with severe mental illness with large ESs. Assessment of LEAS may facilitate the identification of patients suitable for short-term psychotherapy.
(Clinical Trial Registration Number: German Clinical Trials Register, DRKS00000245; Universal Trial Number, U1111-1112-4245)
Journal Article
Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up
Insufficient evidence exists for a viable choice between long- and short-term psychotherapies in the treatment of psychiatric disorders. The present trial compares the effectiveness of one long-term therapy and two short-term therapies in the treatment of mood and anxiety disorders.
In the Helsinki Psychotherapy Study, 326 out-patients with mood (84.7%) or anxiety disorder (43.6%) were randomly assigned to three treatment groups (long-term psychodynamic psychotherapy, short-term psychodynamic psychotherapy, and solution-focused therapy) and were followed up for 3 years from start of treatment. Primary outcome measures were depressive symptoms measured by self-report Beck Depression Inventory (BDI) and observer-rated Hamilton Depression Rating Scale (HAMD), and anxiety symptoms measured by self-report Symptom Check List Anxiety Scale (SCL-90-Anx) and observer-rated Hamilton Anxiety Rating Scale (HAMA).
A statistically significant reduction of symptoms was noted for BDI (51%), HAMD (36%), SCL-90-Anx (41%) and HAMA (38%) during the 3-year follow-up. Short-term psychodynamic psychotherapy was more effective than long-term psychodynamic psychotherapy during the first year, showing 15-27% lower scores for the four outcome measures. During the second year of follow-up no significant differences were found between the short-term and long-term therapies, and after 3 years of follow-up long-term psychodynamic psychotherapy was more effective with 14-37% lower scores for the outcome variables. No statistically significant differences were found in the effectiveness of the short-term therapies.
Short-term therapies produce benefits more quickly than long-term psychodynamic psychotherapy but in the long run long-term psychodynamic psychotherapy is superior to short-term therapies. However, more research is needed to determine which patients should be given long-term psychotherapy for the treatment of mood or anxiety disorders.
Journal Article