Special Article

Psychott!er Psychosom 2009;78:265-274

DOl: 10.11591000228247

Recei\led:FebruJry 19. 2008

Ac.cI.!pted .Iffi' reVIs/OIl: JI.II)I\&. 2008
PublHhed oollne: lull/n. 2009

Short-Term Psychodynamic
Psychotherapy for Somatic Disorders
Systematic Review and Meta-Analysis of Clinical Trials

Allan Abbass a Stephen Kiselyh-d

Kurt Kroenke e

"Department of Psychiatry, Centre for Emotions and tiealth, and Departments of "Community Health and
Epidemiology and t Psychiatry. D~'housle University. Halifax. N.S.. Canadai dSchooi of MediCine. Griffith University,
Meadowbrook, Old., Au;tralia;e Regenstrief Institute. Indiana University School of Medicine, Indianapolis. Ind. USA

KeyWords
Psychotherapy. shorNerm . Somatoform .
Psychotherapy, psychodynamic Psychotherapy.
psychosomatk Psychophysiologic disorders

Abstract
Background: Somatic symptom disorders are common, dis
abling and cost/yo Individually provided shorHerm psy
chodynamic psychotherapies (STPP) have shown promising
results. However, the effectiveness ofSTP? for somatic symp
tom disorders has not been reviewed. Methods: We under
took a systematic review of randomized controlled trials and
controlled before and after studies. The outcomes included
psychological symptoms, physical symptoms, social-occu
pational function, healthcare utilization and treatment con
tinuation. Results: A total of 23 studies met the inclusion cri
teria and covered a broad range of somatic disorders.
Thirteen were RCTs and 10 were case series with pre-post
outcome assessment. Of the included studies, 21123 (91.3%).
11112 (91.6%), 16119 (76.2%) and 7/9 (77.8%) reported Signifi
cant or possible effects on physical symptoms, psychologi
cal symptoms, social-occupational function and health care
utilization respectively. Meta-analysis was possible for 14
studies and revealed significant effects on physical symp'
toms, psychiatric symptoms and social adjustment which
were maintained in long-term follow-up. Random-effect
modeling attenuated some of these relationships. There was

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a 54% greater treatment retention in the STPP group versus

controls. Conclusion: STPP may be effective for a range of
medical and physical conditions underscoring the roleof pa
tients' emotional adjustment in overall health. Future re
search should include high-quality randomized and clinical
effectiveness studies with attention to healthcare use and
costs.
Copyright e 2009 S. Karger AG, 8a1el

Introduction

Half of all outpatient medical visits are related to so

matic complaints, ofwhich at least olle third to one half are
medically unexplained [11. Many are individual physical
symptoms, such as pain (e.g. low back, joint. chest. abdom
inal, headache) and nonpain (e.g. fatigue, dizziness, palpi
tations) complaints. Others consist of a cluster of somatic
symptoms for which the etiology is poorly understood,
such as irritable bowcl syndrome. fihromyalgia, chronic
fatigue syndrome. temporomandibular disorder and in
terstitial cystitis. These functional somatic syndromes of
tcn overlap and are similar in terms of psychiatric comor
bidity. functional impairment and family history [2-4J.
Distressing somatic symptoms are also increased 2- to
3-fold in patients with depressive and anxiety disorders
15,6). More recently, it has also been shown that disease
specific somatic symptoms in patients with a variety of
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J
IIltenlive Short-term DYnamic Psyehotbenpy for DSM IV PmouJity Diso~en:

M'M-J

A Randomized ControDed Trial

Abstract

IrFl.> d J,

({/til

. t;w~fr WJ'~

Thi8 study eya1uated the efficaCy and long-term effectiveness of Intensive ShorHerm ~c
Psychotherapy (I,STDP) in the treatment o~patients with DSM IV personalitY.disorders (PD).

Twenty-seven patients with, PD were ~mized to treatment with ISTDP or a minjmal-contact,

de1ayed-ll'ea1m.ent control condition. ISIDP treated patients improved significantly more than

controls on all primary outcome indices, reaching the nmmal ranges on both the Brief Symptom

.
ol

Inventory (1.51 to 0.51, p<.OOI) and ~nven.tory of Interpersonal ~blems (1.56 to O.67.P<.OOI).

----

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When control patients were wated, they. experienced benefits similar to the initial1rea.tm.ent

group. In long-term fonow-up. the whole grouP maintained their gains tUlLLhad an 83.3%

reduction ofpersonality disorder dia:gnoses. Treatment co~ were t.luice offset by reductions in
medication and 'disability p8.ymeirts. This preliminary study ofISIDP suggeSts it is efticaciOWI .
and C<?St-effective in the ~t afPD. Limitations of this. study and suggestions (or future

research are disCussed.

Key Words: Psychotherapy, short-tenn, personality disorder, psychodynamic

D.r.P.usaw AND ANJaItrr V:f49..-fn (2OOd)

BriefReport
INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY

OF TREATMENT-RESISTANT DEPRESSION:

A PILOT STUDY

AlI.m Anthony Ahbass, M.D., F.R.CP.C.ow

nu

piltIt ~ ~ ti, ~ if ~ SIHwt-.,. lJytutImk

~ (ISTDP);' ~~t1f1 (l'RD). 7M~
DiIh 7llDtHnr~lI_ tiflS7DP' ~ MtntlJNltimt."."..1IIIIl
hUttrjwA'IOMl1llMl'ltllW 'IWn ~ IWI'Y 4 ~ lit --iaIRloa, IIIIIIm

fo/Im.P-tIp. MMltlllil.m., ~. a4 IspitIIl t:OJtI INn tItIf.JIIII'W ~ ",.

II}tIIr ~ .Iff*r-.",..". tf11.6"'" qf..,..." 1IIl .,." "..""..
....w tIM fIWINIl ~ with '.IJUt.., "",p.g"... 0.87 10 3.3. Gtmu
'rlJnY ~1Iud

_fO/Im.P-tIP ~

~ t:eIV _ _ ~ ", eon

~ IIMben;'''".",. TItIs . . . ""'" ~ tIIIIt lSTDP..., 6,

~ uitb this ~~"... A. ~ t:tmtrolIlIdtrlMtmJ
gulittltioll ,adfTlllIn 'I1111mJf1.11J4 to ewdruIte tit, ~ JitrtIm' _ to
~ ltrJ!O#lltk ~~.

20tH.

O2INH wu.;,-u.. k

INTRODUCTION

T reatment-re.sistant depression (I'RD) is a common.

underresearched clinical problem that exacts a large

burden on patients an,d on the health care systclll.
Amiable evidence tI1J8BeSt:5 thAt up to 50-60% of
pati~ts do not respond Idequately to initial antide
p.rc8SIDt tri.aIs [Fava, 2003]. Despite this, thctc is
noted absence of c.lb::Ucal t"Lia1s to support specific
pbarmacotbenpewie augmentations [NelSon, 2003] or
psychotherapies LJ'hase et aLt 2001] in this cballe.nging
patient catest?7. Thus, c:linici.ans arc left widiout
evidence OD which to base clinical decisions.
Comorbid personaliq dDordcn and problema mana
ging emotions have been tou.ted as e.xplsma.tioDII for
poor treatment response in some patients with depres
aion. Patients with personality disorders have defensive
behavi01'8 that can intcm1pt the treatm.ent relationship
[Tbaae; 2002]. Problems ide.ntifying emotions, ale:
ithymia, 'ft8 usociated with the 5en!ti of residual
depl't'.llldve symptoms in one recent
Ogrodniczuk
et al.. 2004}. Gilbert et aI. [2004]
t over 80%
of I. sample of padenu with depJ'8Slion directed anger

tt t:hemselves. Theoretically. any of these psychological

problems can counter the efFecti of clinical mauage
mcnt if they are unattended.

C 2C06 WIIey-LI8a, Ino.

Depnmrm tI'IIIl~ 2..1:449-412,

.

Dtm.nIDo [1987] developed .iDteDsive shott-term

dyDamic psyclaothc:rapy (ISTDP) to t:rDat patientlJ with
depression and persomIity disordcn throush an
emotion-focused process. 'This treatment helps the
to overcome problems in ~ comp1e:z
.
a ptQCeSS iden.ti6ed. as important m diverse
research [Gilbert CIt al., 2004; Ogrodniczulr. CIt ai.,
2004]. In randomized, controlIed trial, ISTDP
produced wperior IUltidepressant effectJ to at more
cognitive" form of psychotherapy In symptomatic

c::;.,

.AuooI* ProfeuOr and DIreGIor of I!duoII\kIn. OtpInment

of P8ychIIdryt Darhoueht UnMnilV. HaIft'aIc, Nova 8cotIa,

canada
ContraA:It grant eponeor: Dettousfe Unlvel'llty. Depar1rnent of
pll)'Chlatry.
*Coneapondence to; Allan A. Abbua, M.D.. F.R.C.P.c 5909
Veteran& Memorial Lane, Room 8203, Abbie J. !.ana Building,
Qell HetIth Seleneaa Center, Halifax, Nova ScoIJa, BaH 2E2.

Calada.. E-mail: .n.n.abbullOdal.ca

Recei'Ied for pubICatIon 30 August 2006; RavIaad 13 DGceI'IIbar

20M: .Accepted 11 Fabrualy 2008

DOl 1o.10021da.202QS

PUbIIahed online 14 July 2006 In WIley Inler8CIence (www.

Intereclence.Vttey.com).
.

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Short-term psychodynan#c psychotherapies for common mental disorders (21(08106

Abstract
BackgroUDd .

Owl the past 40 years, short-term psychodynamic psychotherapies (STPP) for a broad range of

pSychological and somatic disorders have been developed and studied. Four published meta~

analyses ofSTPP, using d.ifterent methods and satDplcs, have fuund conftictin8 results.

Objectives

This review evaluated the cfficacyofSTPP relative to minimal treatment and IlOn-treatment
controh for adults with common mental disorders.

Search stra~

We searched CCDANCfR-Studies and CCDANCl'RReferences on 25/412005, CENTRAL,

MEDLlNE. CINAHL, EMBASE. PsycINFO. DARE and Biological Abstracts were also searched.

We contacted trialI.ists and checked references from papers retrieved.

Selection criteria

./

All randomised. controlled trials (RCf).ofadults with cornmm mental disorders, in which a ln15f. V
psychodynamic therapy lasting 1css tbau 40 hours in total, and provided in individual ibrq.t, were
1ilCiut16d.

Data colledlon & analysis

Three reviewers working in pairs evaluated studies. StiJ.dies were selected only ifpairB ofrevit:wers

agreed they tmt inclusion criteria. A third reviewer W1lS consalted if two reviewers could not reach

consensus. Data wen collected and entered into R.eviInv Manager. Study quality was assessed and

scored by pairs ofraters. Publication bias was asSessed using a :funnel plot. Sensitivity analyses

were also conducted.

Reviewers' conclusions
STPP shows promise, with modest to moderate, often sustained gains for a variety ofp&tients.
However, given the limited data and heterogeneity between studies, these findings shoukl be
interpreted with caution. Furtherinore. variabi!i!Y in tmatrmnt deHyerY and treatment <ffi!lity gy
limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with

~cifiC diilSnoses are waniiited.

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Short-term psychodynamic psychotherapies for common mental disorders (21/08./tI6

Synopsis
Short~term ps)'dlodynamic psychotherapies

fbr common mental disorders

for

Short-term psydJodynBtnic psychotherapies have ~ subjected to randomised controlled tl'iak

a range ofcommon mental disorders. including anxiety disorders, depression, stress-related
~ conditions, certain behaviour disorders and interpersonal or personality problems mixed
with ByllJptom disorders. Previous mda~analyses have yielded conflicting results. This review
included an ReI's ofSTPP fbr common mental disorders, and. fbund modest treatment beoefits that
were generally maintained in medium and long tCDllfbDow.up. However, variability in study design
means that our eonclusioDs are tentative, and need coofirmation with further research.

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Psychotherapy Research 1()(2) 215-234. 2000

02000 Soddy Cor Psychotherapy Research

SHORT AND WNG-TERM EFFECTS OF MEDICATION

AND PSYCB011lERAPY IN TIm BRIEF TREATMENT
0' DEPRESSION: FURmER ANALYSES OF DATA
FROM THE NIMH TDCBP

.j

Sidney J. Blatt

Yale University

I
!

David C. zuroff
McGiU Untversity

Colin M. Bondi
Charles A. Sanislow m
. Yale University

.,on.. -
ences emerJlea at tile ::l.s;.motWflODOWUD in
Of treatment on their life adjustment. Patients in 1FT ~ greater
sa'Bifaalon With treifi'IitW.
patients iii 6@i lP1
~ecj'

,ignllicann=,
_

ana

~ &eililiOril ..
:tfiain~eIPonal
an? to
sources
e
epress on
pahents

at::

ana

!6ei1ib"il
and~

an~
or p

;t;ttfuf

nu; Treatment of Depression Collaborative Research Program (TOCRP), sponsored

by. the National Institute of Mental Health (NIMH), compared two forms of brief
psJchotherapy for the treatment, of depression-Cognitivewbehavioral therapy (CST)
and Interpersonal therapy aPD-with Imipramine plus clinical management (IMl
00, as a standard reference condition, and with pill placebo plus clinical ~nage
ment (PLA-CM) as a double-b~ control (Elkin et aI., 19$). Clinical management
consisted of nonspecific supportive interactions lasting 20-30 minutes (Elkin, Parloff.
Hadley. &: AUtry, 1985). In a carefully controlled three-by-four factorial design, 239
outpatients with major depression were randOmly assigned to one of four treatments
Correspondence reprd,lng tid.. article should be Addressed to Sidney I. Blatt., Room 612. 2S Plll'k Street.
New !:laven, C1' 06519. Telephone: ~735-lO9O; fllt: %Q3.-'785-7357i 8-maU; Sldnll'Y.Btaneylle.iu.

21S

Evaluating Three Treatments for Borderline Personality

Disorder: A Multiwave Study ,

John F.C1arkin,Ph.O.
Kenneth N.levy, Ph.D.

'"
Mark F. Lenzenweger,
Ph.D.
C)tto F. Kernberg, M.D.

ObJective: The authors examined three behaYfor therapy Wet(!! significantly asso

year.lons outpatient treatments for bar ciated with Improvement iii sutcldallty.

, derllne personality disorder: dialectfcal ' Only, transference..focused psychotherapy

behavior therapy, transference-focused and supportive- treatment were assod

psychotherap%and a dynamicsupport:iYe . ated with impl'OVef'lent in anger. Trans

treatment
ference-fDc:used psychotherapy and sup
ponl'll! treatment were each associated
Methoch Ninety patients who ~ elias
with Impl'O'WI!ment In facets of Impulsiv
nosed with borderline personality disor
Ity. Only transferencefocused psycho
der were randomly assi~ to transfer
encefocused psychotherapy. dialectical therapy was slanHlcantly predictive: of
change In Irritability and verbal and di.
behavior 'therapy, or supportive treat
rect assault
.ment and n!CeIYed medication when Indl
,cated. Prior to ~t and at +month Conduslons: Patients with borderline
intervals during a 1-year period. blind rat . personallty'disorder respond to $true
ers assessed th~ domains of sulcldal_ be- tured treatments In an outpatient settlns
havipr. ,auresslon. ImpulsIvity, anxiety, with change In multiple domains of out
depressl,on. and sodal adjustment In ill come. A structured dynamic treatment,
multiwave study design.
transference-focused psythothenpy _
ResuItsllndlvldual (p"OWth-curve analV'" associated with change In multiple con
sis revealed that patients !n all three structs across six domains; dlaledlcal be
treatment croups showed significant pos- havior therapy and SUPPOrtive treatment
. ftlve change In depression,'arudety. slobal were associated with fewer changes. Fu.
functlonln& and social adjustment across , ture resean:::h 1$ needed, to eumlne the
1 year of treatment. Botti transference- speclflc mechanisms of change In these
focused psychotherapy and dial.ectical treatments beyond common structures.
[AmJ ~ 1JJIT1; f64:HI/

Impulsivity. dlminlabed nonaffectlve

coQStJ:ain~ nesa

tive affectivity. and emotional dysregulaUon ate core char

acterlstlcs ofbord.rllne personality disorder (I~). The
prevalence of borderline penoDSlity diaorder In the com
munity cohort of the present study is approximately 1.3~
to l.4~ (4, 5). 'IbJa c;1uon1c and debilitating syndrome 18
assod.ated wtth,.bJgb. rates ofmed1cal and psychiatric utill
zation of ~ (6, 7). Psychopharmacology notwith
standing, psychotherapy represents the recommended
prlmary tedmlqu.e for treatin& borderline personality dis
order (8). Dia1ectl~ behavior therapy (9) baa demon.
&tmted supedorlty over thla.tmeD.t-as-usual (10) and ther
apy by community experts (11).
.
Other therapeutic approaches. sudlu psychodynamic
treatments, continue to be prominent in the treatment of
borderline peltonaUtY disOrder, II supported by the KiA
Practice Guldellne (8) arid prior research (lZ). A Proin1l
log psydlodynamlc treatment approach 18 WI object rela
tions approach caned transference-focused psycbother
apy (U). Transference-focused psychotherapy Ie an '
',;
<0',

effective treatment using patients as their own compari

80ns (14) and hu d~Qnstra.ted superiority over treat
ment....usual (unpubllsheddata byCABinks etal.avaiI
able from the aUthors).
,A necessary and first step in mumtnating eff'ectiw treat
ments for borderline peIllOnaJity ~rcleris to showtbat a
glven treatment iB associated with signtftcant improve
ment In the disOIder-improVemerit in relevant ~men
rdons of pathology beyond self-damaging behaviOrs. Bm
phtcal eVidence should show that candidate treatments,
such as dialectical behavior therapy and psychodynamic
approaches. are Iystematically related to change in a
number of S\1bItantive domams of cHnical sigDific:ance. A
recent influential ~w reported that exi8ting therapies
for borderline personality disorder remaln expenmental,

and more "xeaI-world" atuc:&a are necessary (15).

We examined patients who were.taken from tluI commu
nity and reliably diagnosed with bordexllne personality
d.iBorder. PatlentB weIe randomly asajgned to transference
focused psychotherapy, dialectical behavior therapy. or

>.,,' :",',
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~",."

Am) Psychiatry 164:6, June 2007

ojp.psychlatryOniine.orx

, ~.

Psychor/umztly RetItlrUl, October:l~

I~~,,-

U.D): .562-Si2

j
.~
~~

Reladve efficacy of psychotherapy and pharmacotherapy-in the

treatment of depression: A meta-analysis

s..~KIA DB MAAT, JACK DBKKBR, ROBERT SCHOEVERS) &: FRANS DB JONGHB

Dcparrnmr: r:f Ra.tmdt, M",Q'Um AUmtI1 HII.Ib:1& ~ A~

71u: N~

."..

In the past 25 -,ears, a Dumber of:reviews and meta

analyses comparing the etllcapy or paychotb.e.rapy
and pbarmac:otberapym depression have been
conducted (e.g., Cuacalend~ Perry) &: Looper,
2002; DeRubeis, Gelfand, Tang, &: Si:m.otla, 1999;
Dobson, 1989; Gloaguen, Cott:ra\U., Cucher:a.t, &:
B1ackbuti:l, 1995l Ho~ Jarrett, et aL, 2005i
HollOllt Shelton, lie Loosen" 1991; HoUoD, ~
4t ~ 2002; Jarrett, 1995; Robinaon,
BermaD, &: Neimeyer, 1990; Royal Awnralim and
New Zealand con. of Psychiatriatl, 1983;
SteiJlbrued:;, .Muwel1, &: Howard, 1983; WeinmlUl,
Jarrett, &: R~ 1987; Wezlcz: &: Cicchetti, 1992). It
has been argued that mmy of 1hCle reviews and
meta~ present methodological limitations.
They often do not provide im.ention-to-treat (lTI)
analyses, present effect sizes from which. obviously
no remission rates can be deduced, include flawed
studies (e.g., studies that did not UlH! II1andard1zed
dias;o.ottic c:riteria), and present rcsponee rates
instead of remission rates (Casac::almda et aI.,
2002). An even more important IirDitation may be
the st:riki.nc methodological and c:1inica1 heteropne
ity of the 8tUdiea :Included in most reviewI and meta
analyses. Clinical heterogeneity rd'en to differences
in patient wnplea, treAtr:nent protocol&,. and treat
lllent set.tirlp aa:o. stUdies. We mention t1:tree
examples. In Cuacaleada et 81.'8 meta-atl81yais
(2002), tbtee trial& reprd primary care patients,

-1

~ 11 April 2006; ~ 11.A.pril2OO6)

whereas the other three 1l'iaIa eontider ~

outpatients. T%eIItment duration vadc8 from 10 to 34
weeks. Psydwtherapy conditions iJ1dude oogni.tivc
therapy and inte:rperJOnal ptJeb.othcrapy as well as
problem-eolviug therapy and social work coUJlll.ftling.
In the meta-analysia of Gloaguen et aI. (1998),
Htti:a,ga vari IWeD. more, iDdudiDg hotpital patientB,
outpadmt:5, volunteers, stwimtB, ad~ and
geriat;ric patients. "lh::atment dmation vadea from 4
to 79 weeb. Not amprisiDg1y1l tbe authon ftequent1y
report that tb:: hypothesis of inta:1ri.a1 homogeneity
wu rejected. The review of HoDon, Jamm;, et al.
(2005) ~ priInary CIU%, geriatric and adult
in- and outpatients 8\1fferini from dya1hymia or
IQajor depmsive cUsorder (MDD). A11:hough aome
of the reViewcJ:I (e.g." Gioaguen et aI., 1998) do
address the iuue of beremgenei:ty, most of the
~

and meta-analyses mentioned preriously do

indude atadstical maly8es aaeaaing the influ

ence or the c:Iinical heterogt:neity on the review
outcome. Clinical heteroaene:ity 8.!D.OD8 stu.dieI in
cluded in reriewa or mem-aualyses JIlIIbs data
pooling bazatdoua (aee CocIm:mI ~. HawJ..
book 4.2.2.; Coc::!Jtane Collaboration, 20(4). It cer
tainly does not dow apecitic conclUlions regarding
particular patienm groups or setIiD8B. Hetetogerleity
may provide a partial et;planatlon for the rather

DOt

inCOD.listmt condwlions reached by different .re

views. Many of them conclude that psycb.otbetapy

Cormpondmce: Jack Dekker. ~ of BaeIreb. Memrum Mmal Kealdl AmI'teI.dIm. KlIpi:OlC1lWl& Ill, POII.buI 71_
Amsterdam I (liOA\', The NlldJer!and.
ISSN 10'0-3307 p1'i11t~ 146&-4381 0ftJiDe C 2006 Society for ~ ltIII'eIrdI.
DOl: lO.1080'1050:UOO600T56402

Article

Therapist Affect Focus and Patient Outcomes in

Psych()dynamic Psychotherapy: A Meta-Analysis

Ktarc J. Diener,
Ph.D.
I
.
.

ObJective: The authors systematically

therapist t.idlltllltlon of patient emotiOnal

examined the relationship between !her; experience/expression and outcome
apist facI1ltatfon of patient emotional ex- when more than one outcome construct
perience/express\on and outcome In psy. was included but not when either a slnxte
chodynamic psychothera~
or an unclear outcome construct was
Method: Computer and manual searches used. Th1!re were no signmcant relation
were conducted for relevant publications, ships between methodological quality
and 10 Independent samples of short- . and the size of the effects, although 'use
'term dynamic psychotherapy were In- of audio- or videotaping for supervision
eluded In a meta--ana/ysls. Data analysis . detnOn$1.1'ated :at mode1jlte effect.

'

Mark J. Hl1senroth, Ph.D.

,oel WeInberger, Ph.D.

Included calculation of an overall effect Conclullon.: These data Indicate thilt

size of the relationship between. therapist . therapist fadlltatlon of patient affective
affect focus and outcome, statistical slgnlf- experiencelexpr1!S5lon is associated with
lcance, and test for homoaenelty. In add!- patient Improvement OYer the course of
lion, moderator analyses were conducted
psydlodynamic psyChotherapy. Although
to examine the potential impact of type of the size of this relationship was not signlf
outcome construct used and the method- icant..,. related to methodoloslcal qual~
oIogkal quality of IndMdual studies.
raLllts sugest the Importance of cI~
Results: The overall average weilhted ef- supervision 01 actual techniques through
ft!d size across all outcome types was Ita- the use of audio- or videota~ Addition
tlstfcally slgnmant (r=O.30), and the ho- ally, results hipllsht the Important'!! of
mage-neily statistic was nonslgnlflcant. deffnlng outcome In it multidimensional
Moderator analyses fndlcated a statlstl- way to properly assess theoretically "tie
. cally significant relationship betWeen vanteffects.

(Alii J Psyt;6it1t17 2007; 164.:f36J.U1J

Anwn~
of meta-analJHIII
owrall efficacy

have demonstrated the

of peychodynamic the.rapy or short-teJ:m
d:ymunic psycl:wtberapy acroI8" difleIent types of diaordere
(1-2) and for specific psychiatric diaordere (3-4). Howeve,r,
the rnechanIsmII of actI.on. that IU:COUIlt for this effialcyre

main to be determined, and. studies designed to cl.arIl'y

them represent the natural nut step in research on short
term d.yJJ.amic paycho~ In this type of research, in
vesttga~ seek more speciflc answers to tile ~erennial
qUestion of what worb In psychotberaPlt Rather than 10
cWdng on questions of main effectt (e.g., "Does oognitlve
behavior therapy work better than a control condition
the treatment of major depre881on'-), researchers can
identity potentially more cliDically meantnsful ~ by
-Isolating the correlates of 8. particular set of interventions
'(6), By examlnlngthe potentiallmpactofparticular s.eta of
IntelVentions; ~ben can help dlniciaD8 work more
effecdvely and f1exiblywitb their patient&. 'Ibfa enables c1i

for

:nIdaJis to dlDose from a variety of emplltca1ly supported

lntervendon strategies u approprlllb) undel the dhUc;el
~rathertban betngforced to work w1tbln the

limitations of a single manuaHzed approach for a patient

who has a sped& disorder (5).

.
An affective treatment focus repreaents a releYant
mechanism of action for short-term dynamic psychother
apy, as reaea.teh indicates that contemporary psyc:hody- '
D.8JDic thempie$ place greater emphae18 on encouraging
experience and expression offeeUngs compared. with cog,:,
nitive bebav10rtherapies (6-8).Ablon and Jones (6), for ex

ample, asked expert psychodynamic and cognitiw behav

ior therapists to use a Q-sort-derived questionnaire to
describe an, Ideal paychotherapy of tileD:: xeapec:tive orien
tations. Results indicated that t,he ideal psychodynamic
therapy, In contrast to cognttiye behavior therapy, con

tained agte6ter focus on patient s.IIect. Jones and Pulos (7)

uamlned proc.eI& ratinga of psychodynamic and cogni
tive behaVior therapy sessions and demonsttated that dy
namic therapy contained greater affective emphasis.
Blagye and HOsenroth (8), In a review of the comparative
pqchotberapy process llterature, identif1edseftD. tech
niques Of proCe11e8 that dlstfnguish psycbodynmmcln
terperaonal therapy from cognitive behavIor therapy;

;.;. :... :'-i:~,.~j1~JM~~t.:~~~r~;;:;~;;:;\~,~v~1!:k;}~;;~~~:.

936

gJp.ps)IChiatqMliM.OfI

"",'

Am) Psychiatry 764:6,}UN2007

~~~~._-.&

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_ _,, _ _ _ _,_ _ _ _ _ __

Abstract

~NI.P"am1

CUo PSYchol Rev. 2010 Feb;30(1):25-36.

The efficacy of short-term psychodynamic psychotherapy for

depression: a meta-analysis.
Odesse" J;. GUiioers p, de Maat se, Abbass M, de JQnghe E, Dekker JJ.
VU University Amsterdam, Faculty of Psychology and Education, Department of Clinical Psychology. Van dar
Boechorststraat 1,1081 BT Amsterdam, The Netherlands. e.driessen@psy.vu.nl

Abstract
OBJECTIVES: It remains largely unclear. firstly whether short-term psychodynamic psychotherapy
(STPP) is an effective treatment for depression, and secondly, which study, participant, or
intervention characteristics may moderate treatment effects. The purpose of this study is to assess
the efficacy of STPP for depression and to identify treatment moderators.
RESULTS: After a thorough literature search, 23 studies totaling 1365 subjects were included. STPP
was found to be significantly more effective than control conditions at post-treatment (d=O.69). STPP
pre-treatment to post-treatment changes in depression level were large (d=1.34), and these changes
were maintained until 1-year follow-up. Compared to other psychotherapieS, a small but significant
effect size (d=-O.30) was found, indicating the superiority of other treatments immediately post..
treatment, but no significant differences were found at 3-month (d=-O.05) and 12-month (d=-O.29)
follow-up. Studies employing STPP in groups (d=O.83) found significantly lower pre-treatment to post
treatment effect sizes than stUdies using an individual format (d=1.48). Supportive and expressive
STPP modes were found to be equally efficacious (d=1.36 and d=1.3Q, respectively).
CONCLUSION: We found clear indications that STPP is effective in the treatment of depression in
adults. Although more high-quality RCTs are necessary to assess the efficacy of the STPP variants,
the current findings add to the evidence-base of STPP for depression.
PMIO: 19766369 [PubMed - indexed for MEDlINEJ

Publication Types, MeSH Terms

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Resent-From:
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Date:
To:

stdp..flst@mail-list.com
'*Tony Rousmaniere. PsyO" <trousmaniere@yahoo.cOOl>
[EDT-USTJ STDP research
October 6, 2011 6:53:25 PM EDT
stdplist@stdp.org

New STOP article in the journals...

Exploring corrective experiences in a successful case of shorttenn
dynamic psychotherapy.
Friedlander, Myma L.; Sutherland, Olga; Sandler, Steven; Kortz.
Laura; Bemardi, Shaina; Lee, Hsin-Hua; Drozd, Agata
Psychotherapy, Oct 3, 2011, No Pagination Specified. dol: 10.1037/a0023447
Abstract
The concept of corrective emotional experience. originally formulated
by psychoanalysts Alexander and French (1946). has been redefined by
contemporary researchers to be theoretically nonspacffic, that is, as
"coming to understand or experience an evant or relationship in a
different or unexpected way" (Castonguay & Hill, 2011). Using
postsassion questionnaires, videotapes, and posttermlnation
interviews, we explored whether (and how) a corrective experience
occurred In a successful case of short-tenn dynamic psychotherapy
(STOP; Oavantoo, 1980). A 35-year-old woman suffering severe panic
attacks was sean for 31 sessions by an experienced STOP therapist. The
questionnaires and interviews focused on (a) perceived intrapsychic
and interpersonal changes, and (b) how these changes came about. At
termination, the client reported complete symptom relief. greater
self-acceptance, improved relationships, and more emotional
flexibility. Her corrective experience was evident in the qualitative
themes, which showed that she came to understand and affectively
experience her relationships with both parents differently. Moreover.
the themes reftected both STOP-specific (e.g. confrontation 01
defenses) and nonspecific (e.g., rapport. acceptance) mechanisms of
change. Conversation analysis (Sacks, 1995) of what the client
described as "the 'gentle shove' of questions that make me see what I
have been trying to ignore since childhood" showed, on a
microlingulstic level. how she overcame resistance to strong emotional
experience and expression. (PsycINFO Database Record (c) 2011 APA, all
rights reserved)
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!JIIII:I!~J''l~iJtnIIH(!i~!JHnlJr
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Abstract

IIl fllTat

~AlDI~

~~..f!y'~ia1!I:. 2010 Sep 15. [Epub ahead of print]

A Q,uality-Based Review ofRandom.ized Controlled Trials of

Psychodynamic Psychotherapy.
Gerber N, Kocsis JH, Milrod Bl, Roose SP, Barber JP, Thase ME, Perkins P, leon AC.
From Columbia College of Physicians and Surgeons and the New York State Psychiatric Institute. New York; Weill
Comell Medical College. New York; Department of Psychiatry. University of Pennsylvania. and VA Medical Center,
Philadelphia; Department of Psychiatry. University of Pittsburgh. Pittsburgh.

Abstract
Objective: The Ad Hoc Subcommittee for Evaluation of the Evidence Base for Psychodynamic Psychotherapy of the APA
Committee on Research on Psychiatric Treatments developed the Randomized Controlled Trial Psychotherapy Quality
Rating Scale (RCT-PQRS). The authors report results from application of the RCT-PQRS 1094 randomized controlled
trials of psychodynamic psychotherapy published between 1974 and May 2010. Method: Five psychotherapy researchers
from a range of therapeutic orientations rated a Single published paper trom each study. Results: The RCT-PQRS had
good inter-rater reliability and internal consistency. The mean total quality score was 25.1 (SD=8.8). More recent studies
had higher total Quality scores. Sixty-three of 103 comparisons between psychodynamic psychotherapy and a
nondynamic comparator were of "adequate" quality. Of 39 comparisons of a psychodynamic treatment and an "active"
comparator, six showed dynamic treatment to be superior. five showed dynamiC treatment to be inferior, and 28 showed
no difference (few of which were powered for equivalence). Of 24 adequate comparisons of psychodynamic
psychotherapy with an "inactive" comparator, 18 found dynamic treatment to be superior. Conclusions: Existing
randomized controlled trials of psychodynamic psychotherapy are promising but mostly show superiority of
psychodynamic psychotherapy to an Inactive comparator. This would be sufficient to make psychodynamic
psychotherapy an "empirically validated" treatment (per American Psychological Association Division 12 standards) only if
further randomized controlled trials of adequate quality and sample size replicated findings of existing positive trials for
specific disorders. We do not yet know what will emerge when other psychotherapies are subjected to this form of
quality-based review.
PMID: 20843868 (PubMed as supplied by publisher]

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__.......
Pzvc1w.....~

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.m:Jt., May 2006; 16(3): 293-305

Eft'ects of trabltng in short-term psychodynamic psychotherapy1

Changes in graduate clinician techJdque
'
2
.MARK J. HILSBNROTH 1JARED A. DEFIFB1, MATrHBW' D.
BIAGYS J &

STBVBN

J.

ACKERMAN"

171u Dmw ~ qf~d ~ ~ AdIIph/ UniwrriJy & 2n. Bril Bri1IMm 11111i1uu, .durtttn Rill'
0IratIr, and HM'fJaf'd M.fIiir.4l &Mol
(R.NJrtiwd .if ~ 1003, PIIIfrIIIIIO ~ zot'H;

JO ~ 20tH)

AhIc:n.ci

TId, study investIaatel the drccts of araduatc:,cliniclan t:rai:ntq: insbon-term ~ pII'YChothc:rapy (STPP; Book.
1998; I..uboralcJ, 1984; Strupp & BiDda', 1984; 'Wadlt.el. 1993) an the acipliaidoa of ~ within aad across two
traItDng CUes. SeuioDs 3 and 9 fiom the &rat and. ICCODd t:refltment cues of l' graduate cliDidatui ~ ~
t:ratnIaI in STPP 'ftnI eurninr<l fOr the hqUCllUly of paychaclJDamic-irue.rpenonal (PI) tberapeur.ic: tc.dmiquc:e. Reauka
demoaItuted that &tn1d:lIrCd 1:niDIaa in STPP led 10 aJanificandy increaaed UIIe of PI thcrapeudc ~ both within
and K1'OII cua. 1be IQltho.m alao examined the t'ieqwmcy of copil:lve--bcbmom (CB) ~ tcdmiqneI med by the
fP'8CIute' CHniciItl8. No c:baDpi In the number of GB ~ were obaem:d. over the 8IIDC Bet ofaeuions. PracdaIl
implbtioas for the UIIe of III::nIC:tIJred clirdcal tadnlug and Jasue:a perdnmt to lIUPCI,ision in gradua1e education ate nriewr:d.
~ the impaCt ofstrLlCtUrCd tniniq on azacluaul clinicians" abIJ.tty to lbrm poIdtive ~ relatioDllhlpe with d:Wt
, patieIWi is .tao dIIcuaaed.

The ~tudJ of at:ructUted approae.bet to training and

the acquisition of dhrlcal s.kiDa baa become an area of
inc::reUed Interest ovu the'laar decade. A number of
,author:s have addressed thia iatuc~ and there baa been
the apressed desire for reaeardl on the direct
relad.onahip between training and the IUbsequeot
ic:qviaition of specific clinical IldI1a related to th1a
uaJning (Bcmard &: Goo~, 2004; Bc:Iltler &
Kendan. 1995; Binder, 1999; Holloway "Neafel.d:t.
199~; Miller & Binder, 2002; Patton &: Kivligban,
1997; Stein & Lambert, 1995; Stnlpp, Butler & '
Rosser, 1988; Watkins, 1997). Such evideD.ce of a,
relationship between the tpedficity of'training and
skilllevcl achieved will allow for an evaluation of the
pre:mUe that "akill ac:quiaition in the provision of
paycholosica1 therapies, like skill in pe:r:formiDg any
campIer. behavior, derives more Jioom the uae of
1arJetCd coals. specific feedback aDd guided practice
than &om limple ezposure and ~ super
vision" (Beutler Be :Kendall, 1995, p. 180). However,
there has been limited empirical research concerning
the etfec:ta' of structured "cl.lnicaJ. training' on the
acquiWon of therapeutic techniques.
Some notable ~ reprc1.lng training in

short-term paychodynamic: paycbotherapy (STPP)

have 6een the work of Henry, StrUpp, Buder,.

Schacht, and Binde:r (1993), Mu.ItorJ,; Kiv!igb.an.'
and Gold (1996), at weD. as Criu-Cbriatoph et aL
(1998). These ItUdica baveeraminod the impact of
manuaHzed trII1nin& on ~ acquiJition of psychody
JWIlic thcrapeutl.c akills and pa)'Chotherapy proc;;ese. .
The first of these studies (Henry, Strupp, et at.,
1993) found that, after manualizcd traJnJna in time
limited dycwnic psychotherapy (TLDP; one form of
STPp), therapists were more active in exploring in
sersaioJ1 affect, the therapeutic reIatioJllhip. uaing
opcm-endc(f questions, and dcm~ w:eab::t
adhenmce ~ the treatment model c:onaittent with
the manualized protocol' being . tauaht. This in
creaaed UK of n..DP tedJpiquea ~ .for both
global dynamic and specific nDP mtervcntiona in
the comparlacm of 1CBIi0000fi:om two 'C3&e& before
nDP uaiDinJ with two CII8e8 after t:rain.ina was
completed. In regard to the aapec:rs of aupervbdon
that were moat effective in the development of theBe
tec:bnical ~ Fi.cnry, Schacht;, Strupp, Butler. and
Binder (1993) found '(with reprd to HenryJ.Strupp,
et al., 1993) dear ~ in the dfecIJ that
focused supervision qm ha\'e OD trainees undel'
takiDg st::rUCtUreC! traiu.ing in TIDP. Specifically,

~:

Matt J. HiIIemvth. 220 We!nbcqJ.'Bui1dIn&t 158 Cambri4ae Ave.. The Demer lDetitute of ~ ~GIIl
Stu.diei, AdelpbJ U~J Gardc:o CitY. NY 115~. E-mail: bIIsento@It:Wpbi.tdu
JSSN lMM30? pritltJIBSN.1408-4381 ou11ne C 2006 SodetJ b

00l: lO.1080l1050!3OO5OO26488'1

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January 2005; 15{1-2): 3-7

ORlGlNAL~

The therapeutic' relationship: ~e8rch and 'tlleory

An introduCdOD to the SpeCial Issue

ADAM O. HORVA1H
Simon Fwa8r ~ ~ CaMlltJ
~ 16 N..... JO()f; ,.,;,.d 1 ~ ZOfH; ~ 8 n.c.".hr lOOfJ '

'~

'I'bc pJac:e of the tb.ezapeu1ic ftliariomlbiP 'in p8JCb0tbcrapy resean:h is ~ in .. ldsrorical ~ 1bD.owed by
briefreview of the major xl1l'lCllldl tlumea wkbJn this topic .ad a 11I9iew ofwbatia cow:red in tbB Jpeeial secdon.. Soc:u oftb.e
stten&t1u ofthll bod.y of\'tJOrJr,. 811 WtIll as the ~ ;ball. . . ariaiDs'014 of the re-em~ ofThe~ ... ptID
~ COMCPt c::apt.UI'fn'a ~ n/lational dyDam,iQ' ,of tb.crapyl arc: dfK:uIacd. Jtr.com~~ ibr '~the
~-co.ncr:ptual diaIope on what ~ the ~ ~ in c:Wrerem therapeutia oomat.. aDd:
diSnnt pbues of~ ru:e protided.
' : '

,Ko,wordss ~ -~I).,

Research

0.11

tJIIitmr;., ~ proui, ~ ..

tb.e relIldcmddp ~ thempy ,

The dcdkatiOll of a apcd.al iasue of'~

lbetopic of the therapeutic rcJationShip .
rDuba significant milepost bJ ~ bistory ofempirica1
researeh on ~'process. The. editon~
dec:iaion to devote d:da tnr.teI.1ded ibrmat to the topic 11
, .,mbolic ofa powinarecoanitioD of1he maturity and,
value ofthis body of wotI; 'J;'hiis ps:eaerlts aD important
oppoqtDlityto Umwcaacanew pziendionof~c'
iDquiriea hlgbliabtiDg tome, of the iaaue. dl.aJlen8iD8
those ofuawho dcrdre to moVe the empirical iDYeatip
lion ofthe tcJ,adoDal aspect ofplJCb.otberapyforward~
AI a f.i'ameworlc ibr d:da oveniew of the current
relationahip research ageoda, ~bistorlca1 CODtrst of
,d:da body ofrcaearch wDl be briefly ~ followed
by a aummary of the empirica1 investip.tions of thC
aUiance in
in the past three decacJ.e.,
and moreapeclfically iD tbiaapeclal~ Fmally, the
cha1lcmga lying ahead 8ft discuaIed.
.
~ ;0

psychothen,py

IIlatodca1 CODtext
The relationibip betwecl:l dunpist and client bas
hiItorlcaUy ~ a promiDent ~le in. th~ theories

of therapeutic procc88. In a brief'paper, Preud l8id

the tb\mdatiQn of what wgUzc.t be later elaborated. 81

tl1e concept of the alliance by Uqting the ~ ;
of the development of "the [paticlltl . Ittichf.ht&]

himad! ... to ,d:lC ',dod.Oi'.~. and1inIc [hJm] 'with .

images of people by whom he, WSI aceustomed to ~

be ttea~ witI;1 affccdom.~ (Fren~ -1913). While I
Preud"a Jnsiglmt' hIVe done much to enable ''(l:J.e f
IIJItema1ic ~tion of me;ntsl proc:eaaes, by the
'bqpm1i
of ~ nineteemh '.centa:ry it became t
appareot that, if pI)'choth~Pf WIll u) become 'il
""scim:tificaU,. based. ~onJ it needed a tbeoty :
that could, ge:n.erate robust, ~tab1e, hypo.t:Msa.
The~e of cievdoping,lIll eD1piricaJl.J, tieta- I
b1e model of human change
first taken up by the )'
bChaviorilDl (Skbmer, 19'74). The advamagea a.o.d
oppor.tunir.iea, oft'cted by a model buedon obJerVa
ble behaviors were signifiCant.. However, ~\1d.ing
.,u phc:nOmc:Da beyond that which could. be observed'
and verified It the tb:zie meant that not only the
therapy relationshiP" but cogni.Uve procesaes as
were moved beyond the domain' of e.uqriric:al resea.rdJ.., By the mid.Qle of the twe.t1tiet1i cenNI"Y.
techno1oaica1 .hwdvatiOllB, made it pOlllible and

na

\V.

wcJll

~: MIlD O. ~ CouDIeIHn& PAycholoay P!o&'rIm. SlIDoD. Prucr ~. 88Ba u~ Way, ~ DC. I

~A 186. B-mIik ~c:a

'

ISSN lO=SO-3307 pdAVlSSN' 1~ 0IlIiu0 10 2005 Socbq fbi' ~ Reseudl

DOl: 10.ID8OI10503~lW15!1914'

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piactical to produce live recordings of therapy'

sc:saions opening the way to empiric:ally reliahlc
exploration of the PfOOe88' of psychotherapy. Tbia
new teclmology, and Rogers' interest in the relation- '
~ broadened the horiZon of psychotherapy ~
search. The therapeutic re1ationlhip, became onc:;e
,Qgl$ the ~of attention of some resea.rcb.cm.
While much Of
post-war ~ fbcuSed 011
firidirtg specific ingtedients responsible for positive
therapeutic gains, advances -in ~ eynthesis
(LnborskJ. Singer, &: Luborsky" 1975; Smith &:
Glass, 1(77) yielded compelling empirical evidence
that an -element or elemetm commOn to the broad
a:oss ~ ottherapeutic practicea a.'te responsible
for', Ja:rse portion of beaHnr effects. 'Ibis finding
renewed inteft8t in role of the telatiomhip ,bciween
therapist and client. An esamtial component in the
subsequent 'momentum behind rcseateh on the
~tic relationabip was the theo.rerlca1 work of
Luborsty (1976) aDd Bordin (1976, 1980, 1994).
'Their elabOration aDd ~aion of GreeDaon (1965)
and Zetze1's (1956) work, on ,the payehodynamic '
. ~ of the therapeutic and working a1Uaru:e
:resulted in a pan-theoretical fomwlatiOli of the
, relational co.Dlponent of therapy. '"
'
Between 1975 and 1986 there were a number of
measures developed. to qiJUu:ity the quality ot the
. alHance in helping Rlationahips: While the instru- ,

ment developm.ent and ~t projects opened

the way to investigate. this 'concept, 'there fm1!, ined a

Rignificint reUdual ambiluity abOut the theoreticall

conceptual Ctelinition of the a1U.ance (Hent:achel,'

: 2004; Horvath, at Greenberg, 1989;, Horvath at,

, Luborsky, 1993)~

me

Reeoarch _0IIlP'1.1ah.meDt8

ported acrose ~ have been quite coaaistem: the

aJliance-outc:ome corre1atiOD is moderate but Bigr:dfi.. ,
cant (rmaea ,13:om .22 to .29), clic:nt's Uleninenra,
tend. to be more predictive of outcOme than are other
sources" early allianCe fa as gnod' or better p.rcdictor . ,
of outcome than asaessment8 takeb. later, and the
, alliance as measured' appura to be related 'but not
identical to paraD.e1 therapeutic gaiba.'
,
Somewhat overlapping in tl!!r.m8 of chronology but
distinct in thematic. intere8ta is the aec:oDd phase of
altiance research; these investiptiODB place leu
cmphasisOn the ~aJli~ ~on, 88 such,
and f'oc\1s more on the role, deve1opm.en~ aDd
management of the alliance in tberapy, ioeIt'. For.
eu.mp1e,.rcsearchcrs have aammed SoMints (1980) .
,,proposJtions about f1uctuatioiu ("team' and
in the aUiaD.ee IS core' opportunities for therapeu:1ii'
pin (e...., Sattan &: Muran, 2000)" d.ifre.renca across
clients in terms, of ~ kind o,f relation they desire
with their therapist (e.;., BatdJ,dor, 1988), euin
madon of thcr:apillt qualbiea and ~ors that 'Ire
asaocIated with' client percepdQ1J8 of &ood alliance
(e...~ Henry & Stupp,'l~ HDsemoths Ac:kerman,.'

,Clemence, S~e, &: Handler, 2002). '

,'

repairs"

ChaJleraps ahead

Given the ricbnea and accomplishment oftlUa line of

research, what arc, the c:ha'JJenpa we mJgb.t antici
pate? Pintly, we need
theoretical debate abOUt
the ~ ofthe'~ T.he Idariftlybrief"
period between the initial 'tbeo.rcdcal/~tuaI
for.D:lluation' and the ~. of m~ "
p~ that inpractk:edefined the ~ for
researcli that foDo\ftd Hbly fQredosed'the opportU-'
nity'to examine the implications and p08&i'blc fi:mita..
tiona ,of itxe concept .. fiistpresen.ted by Lubonky
(1-976) and Bordin (1979). MOL'eO'RI'. ,noving the
concePt from i.tB orlginal psycb.odynamic contt:xr. and.
.framirJc it saa pan-th.coretk:al variable isolated the
.niance from a broad theoretical bmework of
therapy and change. Bord:in (1994) began the wodt
of exploring how aspects of the, aDienee miaht
art:ic$te with other aspecb of the:mpy, but these
Brat stepa wete not taken up by otbm, and a nUmber
of importaut unresolved issues remain. Mdit Db
viouslYJ the question wbether the allianCe is in.ttselh.
curative CODlponCllt of therapy, or whether the
.relationship creates t:he inte:rpersoJlll1 conteXt necet- '
sary for other tbera.pcutic e1em.entu.to come to bear
on the. client'. problema. In addition the dynamic
IMllution ,of the thirapeutitrela:tiombip over time
end ,perhaps ira UDique unfblding wtthln pardeular .
diapottic c:oDtext needa t(') be in'Veltipted. '
Second; the field needs to struggle with the
question of how merapism am be trained to develQP

more

>,

>

It ill uaefoI to reflect on the &rOwina' volume. of '

raearch 011 the alliance u represenq two eomo
what chronologically and' topicanY overtappin&
phases: initially much of the investipton' energy
focused on exploring the relation between the
alliance and therapy outcome acrosa various helping'
C01lteXtR. "The ftrlety of COnteID explored in tbIa
phase included
typcB of rreaunenta"divcrsc
populadoDBand diaplostic catc!:goriea, gender ef
fects, 88 well 88 some' therapist !acton such as'levels
, oftherapiat t:tai.nhic and experience. Another area of
inteR8t from. the beginninr was the relation between
Out<:Ollle and alliance aaseued from different per

different

(i.e., client, therapist., and observer) as well ,

as the mapiliude of the alllmceIoutComc relation 'at

diffetent pb.aaes of therapy (see Horvath at Dedi,
2002; Horvath &: SJIllbndl, 1991; Manin, Ganke)
& Davia) 1(00). At a riD: of lIDoring complexity, a .
reasonable summary is dlat the r~ati01l8hJp8 re

mMllr:.h Qftrl rIMor:J 5

be' due to such "bomopneity myth... A more

better a1liani::es with their cliental IDitial etIom to
train therapiats teBUl.ted in paradoxical effect. mmy
detailed and diac.ri.mmaring examination of diema'
and col~ (1993) ~ the results of what
c:xperieoee of the tbt:rapeutic rel8tionahip in. latc:r
app.,..ed to be' an excelienr i:raiDh\a Program; but it
p.huu of tbi: wort, ~ within mediu.ni and'
failed to improve the quality of atunce in therapy.In.
IODF tam t:1'I:8.t.I::Ilti might n:vea!' distinctioaa
UIeful in' ctin.ical practice, research. aDd Uaimng., .
a recent 'IeView' of research on ~ therapista to
develop Btl'ODg at1iances,Horvath (2004) reportC!d
Fourth, .weneed to esamme the sinDlarity. and
tba:t _ than half of the projectll surveyed obtained a
d.istin.ctivenea 'of the aIliaD.cc concept compand to
pot1tive rehnionship
alliance trainina and
other relationship variables. A recent "state at the .'
i:Iie quality of the s16snce a88C8Sed. by the client or an
art" su:tnmary of empJric8leVidenctl on: the eOicacy'
indepei:ad.mt, tater. The review aIao iodiarted. that
of thcmpiau' .comlibudon to
therapeutic reIa
tionibip (Notcroaa. 2002) ;dentified 11 relatiombip
inVestigators were more amaistcnt in idcn:tifymg :
therapist attri1JuIa (sw::h u fleXibility. ini:erest; and .
faerors aspotential coDll'ibutOt'8 to t:b.eJ:apy eOicac:y:
warmth) than thera.piatJ aaifJititIs, anoc:lated. With
Alliance, Cohesion. Bmpathy; Goal Conaenaua and
positive or Im,prOvina a1lianccs. It was also 'notedthat
Gollaboration, Poeitive Regard. ~ ~
.all 'of the succeseftd training project8 Utvolved
back, Repair of Alliance R~ Self Dieclosure,'
. Cou.nter 'lrmafcrence (m.anagem.e:I1t of), and .],lela
'individual supc;msion of train.Ces; .most oftn within
Ii ItrUCtured format (of both supe:rviaion and treat
tional Intmpretadon. The si&1'jfi~ overlap evident .'
ment), ao.d these 811ccessfu1 training programs each
among these elementa~J and the lack of 'a conmade use of, the therapist currt'!'n.t problematic . .ceptual model kni!ng these e:tem;entB iDto a cohesive .
relatioriahip,with their cU~. Tbeie fiD.dinp ~' .' fiamework,: su.agests that tlicre 'is' a need to make
some c:1atifkatiooa and distittct:ionJ.
to.soaest that it is important to more cl~ identify
the :iiUeractive elemen1ll between, 1;berapist and client
'The time la' ~ to renew.rous cfia1o...
related to the alliance, and we need ~ :find methods - gue to clar1fy what we I:Qean by the concepts-Hated
notions IIhare, and wJurt'uacful .
to identl1Y and manap therapists' probl~reac , a.bow. What do
, dietinctiona m8y be made betWeen them?
tiona to cliema in order to improve tb.eir~onal
e:ffectiv'enes. (Beary & StrUpPJ 1~94; Safran '&
Mm:an, 2000).
Conc1uaimuI
".I'bird, we need to examine chaDges'io the qwdity
The bqer <:or:itat of the R8Carcb-on the tbc:raiseutic '
cd' the alliance over tJme. The majorilJ of the
J:elationahip is the ovcrarching goal of underaou.KiiDg.
,available researdl iii based ,OIl the alll1JDlP1:ion that
how' thcrapyworll:\8,. and of
wbaJ'~ glean to
a posii:lve' alliance has the same quality over the
length of tteatmcrlt. P!ogressive enricb.mem and - ,from a clearer' ~emaadjog of tbe payclwtherapy
. pf0Ce8S lCadmg to better practice. The more we
crimplexi1:J is a characteristic of all intimate rdation
undentand how C:liems .ab8O!b, 1ItOre~ and retrieve
ship over time, SO why should we 8I81lD1.e that this is
features of the telationahip with their thezapist and '
not the case in th~? The qualitief of air~mem:
usc: it to ic-imagine -their aituation and- e::r;pand tHe
or .consensus on bonds and tasks, the formation of 8
optiona they have I'available, and the bCttet' we
caring and tru8tfnC reJa.tioDSbip. ~ even emeqence
mulerlltand h(JW the' therapiSt can aeate opp,ortu
of a coDabotativc 8'fIJlce, arc likely J'eUObably uni
Dities to enbal'!cc 1:b:i8 proceea, the z:nore We :On the
form. requirements typicalof.the beginning phase of
blanb in the puZzle of humart change lind groWth .
most tllerapics. It is also EeaIOD8hle to 8atume .that
pzocesa..
.
these issues retain SOIlle rc1evance in later phases.
As several papen inthis volume ilhlstrate. research
But u the J:datiOl'llbip evolves and becomes more
on the relationship can lead us to better" idcp.$Y
complex and III therapy evolYCII and the client
patterlll that locate apecific ~ ~ wbich
exposes more sensitive matetial. the ptooenes like
asreemcint on tasks and goals become ~ . , can fill important zaps in our und.erstmding ofhow
tht:rapy worb.Examples of hm:stiptions reported
embedded in the therapy routine. itself. It baa been
in
this aec:tl0Il with theory builc:U:ng poteDJia1. Jndude
sugested (Horvath~ 2003) that qualities such III
'papers on how c]ientB interpret therapist.. bdJaviOl'8
. mutual reflexivity and. the .permission 'to critk:aUy
(Benecke et 11'$ 2004; Cupat' ft al., 2004), cogniDve,
and mindfully engage in a discourse about. the
process that play t,brmadvc and maiotenan.ce rOle
immediate here and now relational pattern in the
in forminc a poaitive icJ.adonlhip with the therapist
therapy room may be more appropriate in discrimi
(casey ft at., 2004i Rumpold et iI., 2004; SextOn et
nating the mature phase of the therapeutic alliance.
al., 2004)~ III well as t:he identification of clinblly
The lack of success in ident1f.ying what Bardin
impor1:an.t tre~ent ch.aJlensesspecific to pmsoa
(1980) predicted u "different [patterns of] alUancet
ality and diagnostic features (.Li1ijpardi et aL, 2(04).
correspoo.dins to differeut kiodl of treatments" may

between

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Psychotherapy Research, September 2010; 20(5): 526-534

R~,,-

The relationship between insight gained during therapy and long-term

outcome in short-term dynamic psychotherapy and cognitive therapy
for cluster C personality disorders
HAVARD KALLESTAn1,JAKOB VALEW, LEIGH McCULLOUGH3 ,
MARTIN SVARTBERG'\ PER H0GLEND', & TORE CHARLES STll..ES:Z
I Division of Psychiatry, Department of Research and De'lJeiopment, St. Olav's Uniwrsity Hospitlll, Trondheim, Norway;
aDepartment of Psychology, Norwegian University of Science and Technology, Trondheim, Norway; 3 Department of
Psychiatry, Harvard Medical School, Boston, Massachusetts, USA & Modum Bad; 4Department of Psychiatry,
Diakonhjemmet Hospitlll, Oslo, NOTYJJay & 5Department of Psychiatry, University of Oslo, Oslo, Norway

(Recsiwd 25 JuM 2009; TnJUion ",cei'lJed 30 April20IOj

~d

30 AprilZOIO)

Abstract
This study examined whether 49 patients from a randomized controlled trial developed insight during therapy and whether
insight predicted long-term outcome in short-term dynamic psychotherapy (STOP) and cognitive therapy (CT) for Cluster
C p.::nonality disorders. Videotaped sessions early and late in treatment were analyzed using the Achievement of
Therapeutic Objectives Scale. Patients'level ofinsight increased significantly during STOP but not CT. After controlling for
early symptom change and early insight, insight near the end of therapy predicted improvement of symptom severity and
interpersonal functioning during a 2-year follow-up period. These results support the theoretical asswnption that insight
may be a factor in the change process, central to STOP. Within CT, gain of insight did not predict long-term improvement.

Keywords: personality disorders; process research; psychoanalytic/psychodynamic therapy; cognitive-behavior

therapy

A meta-analysis has shown both cognitive-behavioral

therapy (CBT) and psychodynamic psychotherapy to
be effective treatments for personality disorders
(Leichsenring & Leibing, 2003). A randomized
controlled trial comparing the outcome of short
term dynamic psychotherapy (STOP; McCullough
Vaillant, 1997) and cognitive therapy (CT; Beck &
Freeman, 1990) provided further evidence that both
therapies are relatively effective treatments for Cluster
C personality disorders at termination and are asso
ciated with additional improvement during a 2-year
follow-up period (Svartberg, Stiles, & Seltzer, 2004).
The authors also found that the therapy sessions in
STOP and CT contained different interventions in
theoretically coherent ways. STOP therapists focused
more on work with defenses and the transference,
and CT therapists emphasized supportive strat
egies, agenda setting, and homework assignments.

Although there was a demonstrable difference in

technique, we do not know whether these differences

were associated with different psychological changes

during therapy.
Tentative evidence that different therapeutic foci
and techniques can be associated with similar
changes in the patients' experiences was pro
vided by Ablon and Jones (1999). They found
that, although there were important differences in
the delivery of interpersonal psychotherapy and
CBT, characteristics associated with positive out
come were similar in both treatments and described
patient characteristics (e.g., "patient achieves new
insight" or "patient has cathartic experience"). This
finding, and the common finding of no differences
in outcome between treatment modalities, has led
many to speculate whether different therapy
modalities rely on the same underlying psycholo
gical changes (Lambert & Ogles, 2004). It is of
theoretical and clinical importance to establish
psychological changes that are associated with posi

tive long-term outcome in psychotherapy, and there

Correspondence concel'flin this article should be addrtaed to HAvard KaUestad, Department of Research and Development, St. Olav's
UniYersity Hospital, Postboks 3008 Lade, 7441 Ti'onClheim, Norway. E-mail: havard.kallcatad@ntnU.no
ISSN 1050-3307 printlISSN 1468-4)81 online 2010 Society for Paychometapy Relelltcll

DOl: 10.1080110503307.2010.492807

.,z.

'~/oIJ MalichII (2008) 689-;103, 0 7J1l1 Camhl'idge Unlvaslly Prae

doi:lo.1011ISJJ0332C.1~'1Ui"OO164X PrlM!d In tbe UnIted Kingdom

ORIGINAL ARTICLE

Randomized trial on the effectiveness of longand short...term psychodynamic psychotherapy and

solution-focused therapy on psychiatric symptoms
during a 3-year follow-up
P. Knektt.l, O. Undfonl , T. Hiirkinen', M. Vilikoski J , E. Virtalal , M. A. Luksonen l , M. MartNnl!ni ,
M. Kaipainen', C. Renlund l and the Helsinki Pliychotherapy Study Groupl...
1

S4d4llm_'n$lilld/tlll. Hd$lnti, Filll_

~ of "./IJi .IUI Fllrtau-l 0tpariIy, H.,iaMl PwbIk HMlIII blstiM4 HtlsbtkJ. FiuliuJd
flimrefia.m Htbillti. HI/slnti. FiJlJ.t1l4
Dep.m!Ml1 of Pqdri4/ry. Hdsinki U~ Cm/TIIl Hospillll. HuMJ. fillllaltll
Rthllbilit.,/(m fOll_,/tlII. Hds!'1Iki.. f iJlJ.tlUl

BlI(kgrolUld. lnJuHide.n1 evidence exists for a viable dwice between Img- and sholl-term psyc:hodIerapies in the
I:rIIGtment of psydUa\ric disorders, The preae:nl trial compara the tlfectiv_ of one loog-tmn therapy IUld two Ikort
lemI therapi~ in the lreaunenl of mood and anxiety disorders.
Method. In tbe JU,binki r.ydultl"...apy Study. 316 out.patients with mood (g,Utl.) OJ' lU'IlIiety diJOOrd~

wu.,.. w .....

randomly ~ to thn:e treatment groups (long-term psychodynamic psychotherapy, short-term psychodyrwnk

psychotbeta.py, a.nd solution-focused therapy) and were followed up for 3 yvars from start of treatment. Primary
OUb::OlM measures were depressive symptoms measured by self-report Bed Depnl'Slllon Inventory (lDI) and tlbservet
rated Hamilton Depfl!:!l8ion Rating Sale (HAMD), and anxiety SfO\Ptoms measured by self-teport Symptom Check Ust
A:rudety Scale (SClAO-Anx) IUld OOserver-ratei Hamilton Arudety Rating Scale (HAMA).
ReeullL A sta.tistkally significant reduction of symptoms was noted lor BDt (51 "'), HAMD (36'11.), SCL-90-Anx (41 %)
and HAMA (38%) during the !-year follow-up. Short-lerm psychodynamic psychotNlrapy wu more I!lfedlve than
loog.tenn psycllodyJUlll'lk psychotherapy during the first year, showing 15-21% lower scores for the fwr outc:o(M
meuures. During the lleCond year of foUow-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 man effective with
I-h37'l1. lower st'IJfeS for the outcome variables. No statistically $ignificant differences were found In the effectiveness of
the short-term therapies.

Condu5ioAs. Short-term thempifs produce benefits more quicJdy !han long-term psychodynamic psydlotherapy but
in the long run long-term psychodynamic psychotherapy is superior to short-term thefllp!~. However, moN reseAKh is
I'tfeded to determine which patients should be giwn Ioog-rerm psychotherapy for the tteQbnent of mood Of anxiety
diSQrders.
RecdMi 4 Deamkr 2006; Rt!1ised 29 M4y 2007; Atpted 12 Jw1y 2007; fiTSl pub/fWd Mline 16 Nooemkr 2007

Key words: Anxiety, depressiM.long-tmn, psychotherapy, randomized trial.

Introdudion
Mood and anxiety disorders are prevalent and in
capa.cilaling disorders that commonly run a recummt
and <:hronic course (WHO, 20(0). Different psycho.
therapies, short and long, are widely applied in
the treatment of the!;e disorders, and therefore their
efit!'ctive:netIs is an important issue. Clinical trials
Add:rlB for ~eJ Dr P. Knekl, National Public
HcallIl hwIIituk. Mannahcimintir 166. OOJOO Hel:Anld..l'Inlarn1.
(1!m.aII: pauUneldOktUi)

have demonstrated that short-teem psychodynamic

psychotherapy. which. is a brief, focused and active
treatment, is effective in th.e treatment of mood and
anxiety disorders (Anderson &: Lambert, 1995; Barber
&: Ellman, 1996). tong-term psychodynamic psycho
therapy, which is a more intensive approach than
mort-teem psychodynamic psychotherapy, is widely
used in ordinlUJ clinic,,} practice. The evidence on the
effectivenll6$ of long-tenn psychodynamic psycl\o
therapy is, however, limited and entirely based an
non-randomized studies (Piper el til, 1984; Wilczek

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IN J Psyd",wI0/200S:8684 t~6lI

Are psychodynamic and psychoan.alytic therapies effective?

A review of empirical data
FALK LEICHSENRfNG

('lillie ofTielenbrunn and university of GOttingen. von Sieboldslr.5. 03707S Ol:lltingen. Gennany

Fleichs@,gwdg.de

(Final version accepted 5 January 20(5)

17u:re is a need/or empirical ou/come research in psyc'hadynamic and psychoanalytic

thuapy. HCM'(!\<'er, bolh the approach of empirically supported th~rapjes (:)7) and

tile procedure,~ of evidence-based medicine (EBM) haw Se'I!ere limitaliol1S makinf.!

randomised controlJed JriaJs (RCTs) an absofute standard Afiu a critical diSCl4ssiotl

of ,his aplJrOach. the aut/ror reviews Ihe empirical (!\<'idence for the efficacy of

p.f}'dwtiynam,, ps},chOlherap)' in SPf:ctjic psychiatric disorders. The review aims to

icumtify for wltich psychiatric disorders RCTs of specific models of psychodynamic

psychotherapy are available andJor which the)' arlliacking. thus pruviding Q basks/or

planningfilrther research. In addilion,...::;'fU[lS of prot:ess~research ofwc:hodynamic

p!>:vchotherapy are pre.te~ methodology of R"C1:t is not appropriate lor

psychoallalytic thI!NJp)~ effectiveness stztdies ofpsychQanalytic Ihuapy are reviewed as

well. Studies oJpsychodynamir: psychotherapy puhlished beMeen 1960 and 2004 were

identified by u compUlerised search I'-fing Med/ine, PsydNFO and Current Contents.

In addififln, textbooks andjournal arlides were used TwenJ),-/Wo RCTs were ielen! ed

qf which 64% had nol been included in the /998 report

ambless and Hollon.

According to the results. for the follOWing psychiatric dimrders at feast one ReT

providing evidence fOr Ihe efficacy ofpsychtHJYflUlnic psychothuapy was identified:

dCpre...lSiw: disorden f..I ReT.v), anxiety disordl!r'y (I ReT). post-traumatic stress

disorder (/ ReT), somatojortn dLwroer (4 RCTs), bulimia nervosa (1 RC7k), anorexia

nen'o.V{1 (2 RC/S). horderUtIt! pl!rsollality d,:fOrder (] ReTS). Cluster (' personalit)'

disorder (I ReT). and .fuhSll1nce-reliJIed disorders (4 RCn), Ac:cording to re.'tult.~ (Jf

process r~search, outcome in >chodynamic psychotherapy is r(llmed to the ~l11felenJ V

del,i\'I!TYO/lherapeutlt.'fec: iques, a to!

e Qpmen of~l7JfJ7Mic!!.!1JgD.c:e. With

7egW'd to p;;:;ihooiialfiTi:""iIiGapy. controDed qUl1Sf::'6jiii?im~'tmeS$ studies

,
provide e\lidetf<.:e lhat PSYChoa,nolYliC therapy is (1 J mOTl! effect/I'e thall no treatH!,ent (
'77f.'L.
or treatment as Il.mal, and (2) more effective than s1ltJrll!r]orm:i'7!J'psychOdJmamic
'~~1
~lIs1C;iis;;l'e drawtlfiJTflltllre rI!Sf!(l;ar'". - ...
f:!!J<J" ,-,,-.

--...

Keywords: empirically supported treatments. evidence-based medicine,

psychoWlalytic therapy, p.<;ychodynamic psychotherapy, psychotherapy outcome and

process research

In these times of evidence-based medicine and empirically supported treatments,

there is a need for empirical outcome research in psychodynamic and psychoanalytic
therapy (Gunderson and Gabbard, 1999). In a first part. this article presents a review
of the available randomised controll.ed trials of short-tenn and moderate-length
psychodynamic psychotherapy in specific psychiatric disorders. As the methodology
C20M

In~lIlu\e (lfrsycll(lDllRlysi.~

_REVIEW

Effectiveness of Long-term Psychodynamic

Psychotherapy
.
A Meta-analysis
-----~---

Falk

Leicltsenr5 ~

S~n

Ralru!:,& PhD_ _ _ _ __

HE PUCE Of PSYCHOANALYTIC

and psycbodynamic trut

ments within psychiatry is
contronuia1. 1 l Although
some evidence supports tbe efficacy
of shott-term psychodynamic psy
chotherapy (STPP) for specific dis
orders,lo7 convincing ttsearch on the
outcome of long-term psychody
namic psychotherapy (LTPP) has
bun hu:ktng.l,1.8 Evidence suggests
that short-tmD. psychotherapy Is suf

ficiently effective (or most individu

als experlenc:ing acute distress.' Evi
dence, however. also ludicates that

sbon-tenn treatmtDts are insuffiCient

for a considerable proportion of
patients with complex mental disor
ders, ie, patients with multiple or
chrant< mental disorders or person

aUty disordtrs....u Some studies sug

gest that long-term psychotherapy
may be helpful for these groups of
pltients. UOJ ).16 This is true not only
of psychodynamic therapy but also
of psychotherapeutic approac.hes
that are usually short-term. such
as cognitive-bellavionI tnerapy
(CBT).n.l6
Evidence-based treatments ror

these patient groups are particularly

imp01'Wlt. Personality disorders. [or
example. are quite: common in botb
For editorial cOlRt'llflnt tee P 1$87.

Context The place of long-term psychodynamic psychotherapy (lTPP) within psy

chiatry Is controversial. Convlndng outcome reseatch for l TPP has been ladcing.
ObJectIve To examiM the effects of LTPP. especially In complex mental disorders,
Ie, patients with persona.Ilty disorders, duonic: mental disorders. muftlpIe mental dis
orders. and complex depressive and anxiety dIsordefs (Ie, assodated with chronf( course
and/or mlAtipie mental dI$order$), by perfonning a. meta-analysis.
Data Sources Studies of lTPP published between January 1, 1960. and May 31,
2008, we,.ldentffied by acomputerized searth using MEDUNE. PsydNFO. and Cur-
rent Contents, supplemented by contact with experts in the field.
5bIdJ Selection Only 5tudies that used individual psychodynamic ~otherapy
lasting for at least a year. or 50 sessions: had l prospedIve deslp; and reported re
liable outcome measures were included. Randomized controlled ttlais (RCTs) and ob
seNationai studle$ were considered. Twenty-ttlntt studies involving a total of 1053
patien1s ~ fndtlded (11 ReTJ and 12 obIerva1fonai studies).
Data EktndIort Infonnatlon on study charaderist.ics and treatment outwme was
extracted by 2 Independent raters. Effect sizes were cafcutated for overaR effective..
ness, t;lrpt problems. general psychiatnc symptorM. personality functfOnfng. and s0
da! functioning. To examine the stability of oukome, effect sizes wete atlculated sepa
rately for end-of-therapy and follow-up assessment
Results Accotding to comparative analyses of controlled trials.lTPP showed signifi
cantly higheroutcomes In overall efredIveness, tarpt problems. and personality func
tioning than shorter forms of psychotherapy. With reprd to ~aD effectiveneIis. a
betw.,~group effect size of 1.8 (95% confidenceInterval (0],0.7-3.4) indicated that
after tratment with l TPP patients with complex mental disordef5 on ave,.. ~
better off than 96%. of the patients In the comparison groups (P= .(02). According to
subgroup analyses,lTPP yielded slgnlfteant,large. and stable ~n-group effect sizes
across v~ and partiadarty compfex mental disof'ders (ranse. 0.78-1.98),
Co~ons There Is fMdence that lTW Is an effective treatment for complex men

ta! disofders. Further research sttouId addn!S15 the outcome of LTPP In specific mental

disorders and should include cost-effectiveness analyses.

JA/M.1OOB;J(lD(flJ:155115fi5

WWW.jllma.cam

general and clinical populations. IwIhor AffIIIIdIami; O\IpIItrI'JIntgf~ . . . 1I'I4

~rIPJ. u.w.1IlJ of OIlmen. GfBuIn (()t
They show a high comoIbidUy with a ~ and~of ModIcaI~
Gp. university Med1c:al ell'lt" Hal'l1bllt,
widt ran.. Axis 1 psychiatric dis
HiIrnbuJI (Dr~.~.
orders and are significantly associ Eppendori.
t"~II.II' Autllot; Flik lIlldueNl"f. Ok,
17 I
ated with (unctional impainnentJ. 0epatIment of PhoiliOflloltks and PsIJ~,
un~
of C:;1tUe".I.~
Furtb~rmore. a high proportton of ~_
Gemlanl'
(falkJelc:hsenrln&Op5ydto.med
patients in cllnleal populations expe- AIftIo...".Gel,

OHOlA.at:riclm Mr:dial ~ All tf&Iatit raa'fti.

or

7" '"J2

tRepMh!d.I JANIA, Octoborr 1, 2008-VoIJOO. No. 13 1"1

Downloaded from jama .ama-assn.org at Rutgers Unlvel'Slty Llbrartes on August 12. 2011

------

Revi

and Overviews

The Effectiveness of Psychodynam~c Therapy

and Cognitive Behavior Therapy in the Treatment

of Personality Disorders: A Meta..Analysis

Falk Leichsentlng, D.Se.

Eric Leibing, D.Se.

Ob~ The authors conducted a

metHlnaiysTs to addl'l!:U the effealveneD

of psythodynamic: thetapy and msnitrve
IJdtavlofthenlpy In the treatment of persooalty disorders.
Melhodl studies of ~amlC lbGrand iilnltlve bavlMtherapy tNt
were pubfi3 ii&en 1974 Ina 2001
were COllected. Only studies thlit~] us8d
standardIzed l'I'Idhods 10 dIagnoSe personallty dborders,;ij applied reIlabieand valid _
Instruments tor the assessment of out
mme, and 3) reported data that allowed
alculation of wlthiD-grOUp effect sIl2S or
assessment of personality dborder ~

aex

ery rates were Included. Fourteen studies

of psydlodynamkthera py and 11 studies
of cOIT'lItJve behavior therapy were
included.

mNw....

__...__ ._._. ~..__. ' _.~. _ ~

r
a!!!.~

~n!5..

spondinsvalues were 1.00. '.2n. and 0.81.

For more specJflc measures of personality
disorder pathology, a &arp Oetall dec!
slm (1.56) WlS seen for psychodYRItI'I\lc
therapy. Two CDp1ItIve behavior therapy
stuilles reported significant effetts for
ITIOR! spedfic mcasum of per.sonallty dis
mc ~.
order patholo&v..g:
apy, the effect sizes1i1Otte iOna:term

SdVna

,!i*lliin @tetm
BY~lgdm.

Conch_om; There

<srw m!!?nal

is evIdence that

both ~
cognI

tlve behavior '\berjlp ~~e treat

msn1I pi' Rmona1fly d'Isordel's. Since Itte

number of studies that <ould be Induded

In this ml!la1nalys/s wellmla.d. the can
elusions that can be dnlwrl are only ""'"
iiiilijiry, FGrtlii!f nUdia are necessary
tn.t examine spedflc..!orms of psycho
O'rieri'
thenlpy for specific typ~
p~1lty
disorders ani! ~t use ~~~I.!'!!-of <ore

and

psychopatholo~ iOffiTonset: treatmems

and follow-up 'ii"iaiiS shOUI3 le'lncIuded.

IAmJP!Jdklfl72fH13; ffO:l-101

PersonalltydiJorden are cbamcterlzedbylong..stancUng

and. pel'YUlve dyafunctional panerns of cognition, dee
tl'1l1ty, interpersonal rel.a.tionS, and lmpulae control that
calISe coDSlderabJ.e personal c:Ost.reo (DSM-M (1, 2). In
subjects with pereanallty dIso.rderaJ psychosocla.l1mpe.lr
m811t and the we of
health resources is blgb. (3-5).
'I'he prevalence of pat1enta with personality disorders in
Inpatlent and outpattsnt psychiatric populattoll& J.s h1gb.
(e.g., the prevalence of bordedlne personality disorder .Is
estimatedto be betlvasn In; and 259(,.\6)). Howeva.r. there
Is acon&ldemble ladt of emplrlcal research on treatment
of p830UUty dJaordets with psychotherapy. with only a
few rando~ controlled studies (7}. 10 addreH COD
eetnsaboutco8taofmentlIhealthservlce8,emptrlcaldata

mental

about the efflcacy of psycholherapy In the treatment of

personaltty d18order1 are needed. 'filere 11 evidence that
psychotherapy10 pneralll an eifective treatment for per
Bonallty dIso.tdll'8 (7. 8), but ex1&t1nS studies indicate rbat
outoome may dIfter f'or dUfel:ent forms of psychotherapy
(9.10) IWd d1f1'enmt peraonalltydlsoJdenl (n. 12).
Am J Psychldtry 160fT, july 2003

Po[ tbls reason, tb.Ia mlew gamlned the effects of the

two moat frequently applled forms Clf psychotberapy In
me treatment or perso~ dbJorders, psychodynamic
therapy and cognW:ve bahav10r therapy. Our revlew ad
dressed the following quee"t1ona:
What 18 the evi.daIlceofimproWmlWtiD symptomJ,so
dal tunctiDnlng, or COle psythopatbolosy after psycho
dynamic dler:apy or cogD1dw behaviorrberapyf
Is rhere evld.en.ce of improvement In specific types of
personality d.Isordars after psychod.ynamlc therapy or '
cognitive beh.'vior themPJ!
Do tndlvldua\s w1tb pe!8ODaUty d1sorder8 recQV8r a1ter
paycllodynamlc d:tm'apyor oogoltl. behavior tberapy'l
Ate there d1tferences between self-report and obIIerw
tiona!
... measwest

Is thete a comlaUon between outcome and duration of

tteatm.entf
What odler factors are connected. wtm outcome (gen
der.inpadent versus outpatient &tatull. use of tberapy
manuals, upetl.enee of therapJats).
hftp:I/aJp.psychIoUyoI'llIn&OIll

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COMPARATIVE EFFECTS OF SHORT..TERM

PSYCHODYNAMIC PSYCHOTHERAPY AND

COGNITIVE.. BEHAVIORAL THERAPY IN

DEPRESSION: A META-ANALYTIC APPROACH

Falk Leichsenring
':, Uni~ty of GlJttingen

,,
ABS'I1tACT. nil rptU:I6~ 1MeJ}imcj o/~ ~~ ($TPPJ

r.

in MJnasUm ~ 10 ~ thIrrI;j (CBT) (If' ~",..., (B1).

tAU
~ iii 'tIII&idJ alltmt 13 ~ ~'IiIm~ Iaaw bam ~ _
GI iufJicMm 1U&Mr off1aIJmtJ ",. group rum tntaIItl (N..I!!: 2IJ). HttI& "JU'1l to outaHIW criUritJ"
lhl t'I'IUbsfll'llmr~for~ in ~~, gtmmsl~ ~
msd~~ SUt . . ._ tJui1ldu.rion eriIIIri4.lWults: In58 t1ftluJ6() ~
(9'1~) ~ ift tIuJ_~ _",..~ no~dijJimm.u could f~
~ srpp tmll C11I'/lII' emt.t:Imritag tJu #/fodI in ~ ~ IJfM'Gl ~

(m"

~~

oft4 SfIdalfo~ ~ STPP _ CBT/KI' di411Dt tliffe'sipift

crmu, midi ,....,., 10 tM patimts thal __ juIf,rKl tU nmdtkd CIr imJwowd. A~ to " fIIIItao

~~~"R. &smtIud (19:91) tJusludiatlo tsotdiffi:r~ witA tit

gtml to 1M /KIfMaII thtsI ....ftMlBt!d '" ntIIittlClr iwrfmJwtl ojtIr ~ t&Iit1& $TPP or CBI'I
BT. TM mm tMffemau~ STPPmul CBTIlfI'.~tM~of~ tIiaItlM'I'f
judpllJl mniItId ari'WJ/1rrlflld ~ to II mall;#ffoa du ~ q, = 0..0a. foI
lupw,/J ~ q, - 0.1!). 1lnu~ STPP tJRtJ
11m 10 f~
fIIdhJs in
lM tfrtJI,,,..,:~. HtIfIItIIII!i. Cu...... ht. _ ...11 _ _ x::: ::J ,;,;0;:...4 :::;;, ,.,,~ -~
~ crittt1ia,
7IIfIll . . ..

arr.nrr

f:::

.I

I
I
'/

Correspondena should be IlddreMed to Dr. Faik. Leichsenrlng, University ofG6tlingen. Depart

ment of Psychosomatics and Psychotherapy. Von SkbolOatr. 6, 1)-37075 G6t1ingen. Cennany.
40J

Short-term psychodynamic psychotherapy: review

of recent process and outcome studies
Andrew J. Lewis, Michelle Dennerstein, Petah M. Gibbs

Short-term psychodynamic psychotherapy (STPP) is a widely practised form of

psychological intervention. Given that the Roth and Fonagy (1996) review concluded
that there was a lack of confirming evidence for STPP, the current review is focused on
studies published between 1996 and 2006 that evalllate the effmcy of STPP. As a restJIt
of a systematic literature review. 18 studies were found that met inclusion criteria
consistent with those used by Roth and Fonagy (1996) for selection of studies, patient

groupings and definition of therapeutic method. In general these studies add to an

increasing body of evidence suggesting that STPP can be an effective psychologlesl

treatment for individuals experiencing mental health probtems. Specificatly, for
depression STPP oan be equal in effects to other psychological treatments and is
significantly better than no treatment in the short term. Furthermore. emerging process
data indicate that there is a significant relationship between the use of SpecifIC
psychodynamic therapetJtlc techniques and the alleviation of depressive symptoms.
Jncreasing evidence has emerged to support STPP as a treatment for generalized
anxiety disordar, panic disorder and some personality disorders. There remains limited
evidence for the use of STPP treatment for patients with anxiety disorders that relate
more to stress. Very limited and inconclusive evidence currently exists to support STPP
as a treatment for bipolar disorder, eating disorders and drug dependency. Future
research needs to include broader assessment measures, long-term follow up, studies
tilat maintain an Identifiable focus, and research that tndudes a fcx:ua on psychotherapy
process variables as they Interact with outcomes.
Key words: outcome assessment (health care). psychodynamic therapy, shon-term
psychotherapy.

E
.

,g

i
!
~

I
i

Australian and New Zealand Journal of Psychiatry 2008; 42:445-455

Psychodynamic therapy continues to be a popular

therapeutic approach among clinicians, with 14
40% explicitly subscribing to this orientation [1.2].

Andrew 1 L!!wIs. SenJoc Uclurtr in P~hoJolY (Correspondence)

ScIIOII4 ., ~, facultJ of Ret" Me4Idu. NunIa& ami

lWIa,iounI SdaKa. De.ld. ~tr (W.ecrfrolll C.....,. GeeloIII.
V"\( .1117. AUillralil. Email: udrew.ltwis@4tu.ta.......
Mjc.helk: ~t~". Mill\ef1 Sludcul; I'ttab M. Gibbs. Lt;1'\lU1Or m
P~holoiY

SdIooI of Bt:IIInlolll'ai uti SocW sa.- ud Klmuultdls, lJ.mnl1J' ar

Ballarat, Bdanlt, VlcrDrIa, Aamlllla
~ivtd 16 kpkmber 2007; IICcqltcd 20 janUAry

:zooa.

C 20011 The Roylll AlalUalian aIId New Zealand eonq.: at Paychialriw

But psychodynamic therapy is frequently criticized

as lacking the evidence that would justify its use [3].

It is therefore notable that during the last decade
high-quality empirical studies have been produced
that respond to this defidt. The aim of the present
review was to evaluate the efficacy of short
term psychodynamic psychotherapy (STPP) using
a systematic literature review of studies produced in
the decade 1996-2006. The review is structured so
that findings can be used to inform the clinicaJ use
of STPP according to OSM-IV diagnostic cate

gories.

~ DI5'b:t I'ht 1iIIIciIiIaul,........,.......s

~32MD!I$11iIO

DC)(: lO.lOJ7.om-~1.I5

. CL:QtNl' ~TIACBMENT T-o THERAPIST, DEPTH OF

. IN-S;ESSION EXPLORATION, AND OBJECT RELATIONS

.
IN BRIEF PSYCHOTHERAPY

BRENT MALLINCKRODT, MARY JO PORTER. AND .

DENNIS M. KJ.Vi.JGHAN JR.
..
Untv~rstty

of. Mwo~rl-Columbia

A growiDg body of evi~ suggests'that eli

cnfS. adult attachment ,sty~may .\le an.imJ?o;
38) in lime-liiilited tMrap)1 comtant infl~ on the ~~odH::rapy relationship
. ,
,.
. ' (for n.mcws;ace Mallildxodt. 2000; Moyer &.
.
the Expel'WlC8S rn Close Rela
Pilkcml&. 20(1). Howev~, tho recent ~
lonihips Scale.as a measure of adult
Psychological AssOciation Division 29', Teak
jitachment. the Ciient Attachment to.
Faroe ~ PSY~PY ~~;pa CODC~
f'Mraplat 'Scale (CA1S) Working AUi
that ovuleDCe 18 aa yet "'insufllcient to make a

stti:es explored attachment in

richotherojJy. l~ 1M 1st stwJ.y, clients

"

Inventory (WAl), and measures of

depth am:J smoot/u;&ess. Cowwith J. Bowlby's (1988) concept'of
a8Cllre base promoting greater apia- '
........I r . cinachmmt to therapist '
-

was asSOC1

with iluecure therapeutic attach.;

clear jndgment" ,bout whether custorrUziDI the

therapy relationsbip to IJOOOW1t for cnem attach
,ment style Could: make a positive CODIrlbption to
treatm.eot outcomes (Ackerman et al., 2001. p.
496). In reapbD8e ~ the Task: Force's, call fot
DlQI'8 research,. we exp~ ~ follOWilltt tbccc
resean:h questiOIla, wfW;.h we felt were useful
neXt steps in Ibo application of attachment theory

to psychotherapy research: ,Ca) Prom 1be starJd-'

pojnt of BowlbY's (1988) concept of li!cun bau
for ,exploraJion. is ~ security of a client's
attach:meDt to hb or her tborapist associated -with ,
tnClIe exteIWw ~-session Qlr.!rapeutic' eJpIora-,
don? (b) ~w clo8e1y,doea the Il118clnncm! rela
tionship between client and therapist miuor as
pects of the client's otIJC cJ.ose attacbn:umt
reIaIionships? (c) Can ~ coustruct of client at
tachment to tbeiapillt explain SOIlldhipg nniq~
abOut tho psychotl:ie.rap process Of' the client that .

CATS subacalu predictet;l ~ique

'variance'ln sesawn, experience not ac-,
countedfor by die WAI alone. The 2nd
8tJIdy was a'new analysis of datil origi
nally reported by B. Mallin.ckrodt, D. -,.. ,
Gantt.,and,H. M. Coble (1995), Among
women cUents (N = ,44) who completed is nOt explained by the working alliance?
the CATS. WAI. and the Bell Object
Rek#Wns and Rlality Testing Inventory. J\ttach1Dellt 81 Seeure Base for &pIoratioa
2 CATS 9ubscales predicted unique '
',B~ (1969,. 1973) held that from 8Il etbo
variance in object relations clejidts not , logical perspectiVe, die auacJmwtt of youiiS chil
dmn to' their caregivers involves two behaviOral
" accounted for by tM WAl alone.
.
.'
.
1M1I1.

"

'

systcms--t proXimity-seekiDg attacbme.Dt system

and an ,exploratory system. The two Iystems are .
complemenraiy in chat as one becomes activabJd,

Bfeat Me11inekrodt, Mmy Jo Porter. IIId Dcau.Ia

Xiv.. the other'is ~m~ ~vated. Beawsc .
IIp-a Ir.. DeptrtcneIIt oflldOOatloua1, Scbool, amtCOWlllel,hmnan,offspriDa are bam relatiVely hcJpleu and '
1Ds~. Uo1YCrtUy of Miaaoud-O:Ilumbia.
,this al~ period continues for several years.

M.

i
,

, Cti.aapoI~"""'v.:e rcpdiDa tI:Ila It'IideIbouid ~ ..~._ItD

-i Brem ~ PhD, Ulliwnlty CJf ~ 16 Hm HIll, .
r Cotuml,8. ~ mil. 'Br-IIWl: ~b.IldPomi.oclu

infantr,~erP,fOXimity i!J cmcial fot: sumVlil.

AmoDg ~ young

of oar distBDt BDCeStors, prox

imity to categivets offered greater access to fOOd. .

f"

. '

'

!,

85

ltd like to discuss what you do for a Iiving-taJk therapy. And l'd
like to suggest something heretical-that calling It UUlIk therapY'
misrepresents and grossly undervalues what you do. It may even
mislead others about what psychotherapy is and how it affects
people. -Talk therapy" makes it sound as if words Issue from your
mouth or the client's and then dissipate in the air around you. As If, as
the sayinggoes. it's cheap-ya know, common stuff.
WHAT'S TO TALK ABOUT?
This is something live been thinking about for some time. But the idea
really crystallized for me a week or so ago. I was at the Saturday
morning Neuro-Psychoanafysls Lecture Series held monthly at the
New York Psychoanalytic Institute. New York University
.
neuroscientist Joseph Lel;)oux had Just made a presentation on the
amygdala and the emotional brajn. He focused on fear memories and
how they are not just one:-tlme inscnptlons in our brain. Instead, they
are reconsolidated and rebuilt every time they are retrieved.

WHAT REALLY GOES ON

As the discussant, international neuroscientist-psychoanalyst Mark
Solms, Ph.D., director of the institutels ~eurcrPsychoanalysis' Center,
pointed out, this new view of memory suggests a way to get
conscious control of a powerful but unconscious emotion..generating
system. "K
f reconsolidatlon, If said So(ms, "opens the
...eosslbUity of retranscriblng memories.
e es
w a really
started a chain of tttougms in my brain. He was talking about
psychoanalytic therapy. but he could have been talking aboUt any
deepJy engaging psychotherap.y. "Psychoanalytic therapy Is not just
talk therapy but involves reactivation of the emotion. Maybe we
should call It transference therapy." Through senSmvei ablY guidld
discussion, emotional merrtQ~es can be thoroughly processed. --

THE SCENE OF THE ACTION

In other wdrds, good therapists use transference-generated emotions

to help a client leam new associations around a distressing memory.
They can do this repeatedly, until the troublesome memory is
extinguished. This doesn't take place In the air. Through the medium
of talk, the brain itself undergoes cha~ge. Every time a memory is
retrieved, it is s
. ad
ebulll in 11
. .kindler, gentlers ona with what is going on at the time. Genes snap to
. attention, fancy neurotransmitters and nuclear proteins swing into
action. Nerve reactivity and circuitry Is aitered. This, ladles and gents.
is classy stuff, and it sits right at the cutting edge of science.
GOING FIRST CLASS

Talk therapy has privileged access to the brain. It works Its changes
on nothing lass than the cortex, the thinking brain. CognItive
behavioral therapy, for example, teaches p$Opie to change how they
monitor the environment, so they do not need to emotionally react to
everything negative that comes their way. Brain scans show that talk
therapy literally changes blood flow and metabonc activity in the
cortex. By ch~Jng the brain from the top down, as it were, It has
.!!facts1f1at last long after tile ihftra~s finished, protectg ag:~
[!Iapse: into distress in a way that drugs can't, because they dO!!'11!

.....educate the brain. _

WHEN ONLY TALK WILL WORK

So priviJeged is the access that talk therapy has to the brain that
sometimes it's the only thing that works. Last year, a large
multicenter randomized controUed trial of psychotherapy versus
pharmacotherapy showed that talk therapy works In some 01 the most
difficult cases of depreSSion. for example. whereas drug therapy does
not. It Is singufarty effective for those wtth 8 history of early childhood
trauma, such as foss of parents at an early age, physicaf or sexual
abuse or negl8Ct..!PsYChOtflerapy may be an essential element In the
treatment of dents with chronlo forms of m or depreSSion ana a
history 0 childho trauma, II tjle researchers repc
In e

Proceedings of the' National Academy of Sciences. And it is so

essential because some' distressing memories can be safely
accessed and reprocessed only via talk therapy.

CAlliNG IT WHAT IT IS
That leads to the obvious conclusion: It Isn't just talk therapy. Dohe
weill it's brain therapy. And, yes, mind therapy. And emotion therapy.
Memory therapy. And. as Mark Solms said, transference therapy. It's
all about the hottest thing In neuroscience today--braln plasticity. I just
want to make sure you are as much in awe of the magic you do as I

am.
'May' wish you a very Happy Holiday. See you next year.

Best,
Hara Estroff Marano
Editor at Large, Psychology Today
115 Ea~ 23 Street
New York, NY 10010
212-260-7210 x235

http://www.psychologytoday.eom

Nt.ss.E: S.6/ +Ab6ss/ll C~C)lo)

SJl d ~ - 6CLS e..d f5'{ c.hod ~ YJafl}( e

Brief Psychodynamic Therapy With Clients With PD

l.(} 1'Itl

"""':---....

P~~

A variety of psychodynamically based shorHerm therapies (fewer than

40 sessions) conducted with mostly Cluster B, Cluster C, and NOS PDs have
been studied in eight randomized clinical trials, yielding robust positive effects
that have persisted at follow-ups averaging 18.9 months (SD =7.3; see the effect
sizes of seven of these studies in Table 4.1). These include three studies that
rely on Oavanloo's (2000) approach, as described earlier in this chapter.
Davanloo's earlier method (before 1980) was found to be similar in overall
outcome to two other forms of more supportive dynamic models and superior
to a wait-list control group (Hellerstein et al., 1998; Winston et aL, 1994).
More recently, his technique has evolved to include methods to build anxi
ety tolerance in fragile and somatizing clients, enabling treatment of a far
broader PO sample (Abbass, 2002). A study using the current ISTOP model
(Oavanloo, 2000) found greater effects with a shorter treatment course than
did Hellerstein et al. (1998) and Winston et al. (1994) even while including
12 out of27 PDpatientswith BPO (Abbass, Sheldon, Gyra, & Kalpin 2008).
A study ofCluster CPOs based on McCullough Vaillant's ( 1997) model
of brief dynamic therapy found positive change for clients treated in this
modality and in cognitive therapy. The dynamic therapy also brought a sig
nificant decrease in symptoms, which was not the case for cognitive therapy
(Svartberg, Stiles, & Seltzer, 2004). In terms ofstrategies, this psychodynamic
therapy uses defense, affect, cognitive. and self-other restructuring as described
in the Mechanisms of Change section.
In a different study, another form of time-limited, manualized therapy,
known as supportive-expressive therapy (Luborsky, 1984), which is based on
standard psychodynamic principles, was compared with community-delivered,
nonmanualized psychodynamic therapy conducted with clients who had
Cluster CPOs; both yielded comparable, positive results (Vinnars, Barber,
Noren, Gallop, & Weinryb, 2005). Finally, brief relational therapy (BRT)
was compared with brief dynamic therapy based on standard psychodynamic
principles and with cognitive behavior therapy in clients with Cluster CPOs
and POs NOS (Muran, Safran, Samstag, & Winston, 2005). The results indi
cated that the three treatments were equally effective, although there were
fewer dropouts in BRT. The strategies used in BRT are to track alliance rup
tures and to communicate about what is happening for client and psychother
apist, thereby cultivating awareness of self in relation to the other.
These data, gathered from a group of reasonably good quality studies
from several different research centers, offer empirical support for short-term
dynamic therapies for a range of POs. They do not, however, indicate the
superiority of psychodynamic therapy over other therapies.

(). HAAV\CUJlf?-(Cd) 0v;~-bCLseJ ~fm:eu{- of

u/' _ /.

J 'P-tVt9c,11 Of)

EVIDENCE-BASEl\PS:<?~ODYNAMIC THERAPY

101

f7JD" 1-G.}- III )~ WiLSlUA,i-~rtvt)IlX-'.t

I"

-" ..
I.

!I..--, .

AfA

~
TABLE 4.1
Treatment Descriptors and Effect Sizes (ESs) of Brief Psychodynamic Psychotherapy
Randomized Clinical Trials of Individuals With Personality Disorders (PDs)

tTl

""

""
~

Ei;
to

2;;

""

Study
Abbass, Sheldon,
et al. (2008)
Hardy et al.
(1995)
Hellerstein et al.
(1998)
Munroe-Blum
et al. (1999)
Svartberg et al.
(2004)
Vinnars et al.
(2005)
Winston et al.
(1994)
Mean (SD)

Mean total
sessions

Mean length
follow-up
(months)

SCl-90, BSI,
orGSI ES

liP ES

GAFES
2.26

STPP intervention

PD diagnosis
(cluster/type)

ISTDP (Davanloo,
2000)
Psychodynamic
interpersonal
(Hobson, 1985)
STDP (Davanloo,
1980)
Dynamic
psychotherapy
(Kernberg, 1975)
STDP (McCullough
Vaillant, 1997)
SE psychotherapy
(luborsky, 1984)
STDP (Davanloo,
1980)

27

A. B, and C

as

24

1.78

1.39

13

12

12

1.21

1.13

25

A. B, and C

29

0.27

0.31

26

Borderline

40

24

0.92

25

40

24

0.95

61

A, B, andC

26

24

0.63

15

A, B, andC

40

18

0.58

30.7 (10)

18.9 (7.3)

0.91 (0.5)

1.04
0.68

0.97 (0.5)

1.47 (1

Note. Effect size was computed by dividing the pre versus post score difference by the pooled standard deviation. Data from the longest follow-ups were used to calculate the
mean treatment effects. Effects sizes of 0.2 are smell, those of 0.5 are medium, and those 0.8 and higher are large. An eighth study. Emmelkamp et al. (2006), did not use any
of the common measures listed. STPP =short-term psychodynamic psychotherapy; Sel-gO =Symptom Checldist-90; BSI Brief Symptom Inventory; GSI =Global Symptom
Index; liP =Inventory of Interpersonal Problems; GAF =Global Assessment of Functioning; ISTDP =intensive short-term dynamic psychotherapy: STOP short-term dynamic:
psychotherapy; SE =supportlve-expressive. Dashes indicate that no data are available.

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-,

Do Comorbid Personality Disorders

Moderate Panic-Focused Psychotherapy?

An Exploratory Examinatio~ of the

American Psychiatric ~ociation Practice 'Guideline'

Barbara L. Milrod, M.D.; Andrew C. Leon, Ph.D.;

Jacqu~ P. Barber, Ph.D.; John C. Markowitz, M.D.; and Elizabeth Gral, M.A.

~111lJ 26,2006: ~dcr. 20,2006. I'lf1IIIIM

/HpG1tmIntofP~w.;(fMtdicfilCoIl~tfCqmellUmmu,
(Drr.ltlflrotI. tIIId Uo1r _ Mr. GITI/) tBtd 1M NfW York SltJ# Psyc/U4trfc
lUlftNle (Dr.MtriDwtt.), N_ forA,- tmd die ~ tfPaydritll".

UIfl--, qfPf1l1ll1lwmJa,PIti1'I.rIklp/fI (Dl'.llIlrtw).

FWti/lJtg l0II1<<I: grrm. JQJMHOJ849-OJ.105 f11Jm 1M NAIioItal

O~c""~: 'l"btAmerican Psychiatric AsSocia

tion (APA) practice guidelina for panic ~

recom.mend8 p8ycbodynamic psychodlc:rapy for

panic cIiIcJrdor ~ wid! comotbld pcmmaJity

disonhn. No data underlie thi5 rec:ommendation.

Tbia e:r.pIoraJory, study allCllCd die uioden.dng

cft1:ct of penooality disorder on psychodynamic

and non-psychodynamic paychotharapy OQtoome.

MduNl: Porty-niDe subjects with primary

DSM-IV paaio dillOt'lklr were randomly llllipod .
10 12 wcclca of twice--weekiy Pani~Pocused Psy
chodynamic Psychotherapy or AppJie~ R.elaxation
Traitdng.11le primary outcome measure was the
Pmic Dlsord Severity S<:ale; the modmaIilll
efft:iGt of Aba II psychopathology Oft !he Sheebaa
Disability Scala was IIlio tc8ted. The trial W8I
coaducted between February 2000 and January
200:5.
R.,JIl16: 1'weoty-f01lt subjects (49") met

OSM-IV criteria for a Structured ClinicallDter

view far DSM-lV Axil n Disordera-diaJllOsed

-personality diIorder, of whom 1~. CZ21l had

1i!:'"

c1'1At~. Presence of a cluster C

nOli.
edt trea1meDt outcome. stlcii au
jeoos oxperiCli&d geiii'iffiPiOVi&iiii In Piiiic

'f~pre1if
.~
~
~.
sample 81ze,
/IJI1IU:

this exploratory analysi.8 provides initial prelim!.

nary cvideRcc CC?fTOboratins the APA practice
JUldelino reco~n. Future panic disorder
clinical trial hould explore Am n moderator

cffeoIi.

ClWcfIU'rl4b Regi.lll'tltlt>lll

QinlcalTrlt.b.IIOV identitler NCl'OO128388.

(J elln PsyclrJatry 2007 ;68:885~1)

885

JIt81ibIu tf ItIDIIiII Htaldt tmd !'JIIIId ill tJu NfW York COtNIRunit, 1}1IJI
UI4blilMd by lMV'1tt ItWlMt.
T1te ardhor, 1CpOI1,., tItIdJtUw:IlflNmc/lll or DIIuIr ~
1'tk1lGlll1D 1M NbJr r.f tAU tll'llc1L

COI'f'UJH1NlIIaI talIrDr tIIId nrprbtll; BarlIrza L. Mlltod, MD.,

~~P~",.

WooiBMttdlc:ol CoIl. ~COl'7Wll ~ky.

S1J &IIIl6&lt St., NN YDTic, Nt 1()(J21

(NIttlII: ~.cor-U..u.J_

he intcncction of the DSM Axes I and n poses

a clinkaJ chaUenae. When clinicians disoover
personality disorders, comorbid with Axis J diagnoses,
should they alter theiT treatment approach? Are particular
therapies more or less likely to benefit patients with mul
tiaiial comorbidity1 Unfortunately, this ~ has received
re1ativoly little attcotion. especially in anxiety d.i.sorder
patient&. The Axia comorbidity of panic disorder is
an interesting example. III many patientl with panic disor- .
dcr also have Axis II diagnOBCll, particularly in the ("anx

ious") cl~ C.
In a descriptive study,' Ozkan and Altindagl found.
panic disorder patients with comorbid personality disor
ders bad greater clinical severity tlCIOU anxiety, mood.
and psychosocial domains than panic disonier patients
without personality disorde.rs: Few studies.haveexamined
the effect of Axis II on panic disorder treatm~ outcome.
In the naturalistic, moltiaite Harvard-Brown study (N
514). Masaion et al.1 found DO negative impaCt UIIociated
with comorbid personality disorder&. diagnosed by Inter
national Personality Disorder Examination.' on time to
panic disorder remission. Another report foWld cluster C
.. disorders were associated with longer duration of panic
disorder,4 potentiallY confiating. apparent moderator ef
fects of clUJtel' C disorders with panic disorder duration,
an identified indicator of poor prognosis.5
Studies of Cognitive Behavioral Therapy (CBT) for
panic disorder have reported mixed effects of Axis n

IPYRIGKT 2III7I'MY8ICIANS POSTliRADUATE PRESS, INC @COl'\'1\11lHT 20117 ~~~~:,'i,~~7

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EVALUATING AN ALLIANCE-FOCUSED TREATMENT FOR

PERSONALITY DISORDERS

..,.~

"

JEREMY D. SAFRAN

Beth UTJI8' Medical Center and

AlMn Ebutein College of Medicine

N(IW School Unlvenlt and

ARNOLD WINSTON

Umg 1sland University and

Bm Israel Medkal Center and

Beth I~l MIdIcal Center

Bcth 13rael Medical C#mIer

. USA WAU.N.BR SAMSTAG.

,.

. \.r'"

.,

J. CHRISTOPHER.MURAN

Alben EinstmJ College o!Medldne

This paper pnsents a study with the

were indicated regarding clinically sig
nificant
chtmge and reliable change,
aim 0/ ewJ1.uating the nlativ~e
of
liance
ed t11
favoring the brie/ rellltUmaZ'and
atlonal theran
conrpariaOll' a
cognitive-behavioral mode", TMre
s.
ic therapy and a
was also a significant dtJference re
cognitive-behavio.ral therapy on a sam
garding dropOut rates, favorl:ng brief
ple of highly c01!J07bid personality dis
relational therapy.
ordered patients. Results indicated that
thl three treatments were equally effec
Keywords: therapeutic allia.ncc. pcrscm
tive on standard statistical anaJyses of
ality disorders, brief psychot:herapies,
change, including those conducted on
treatment outcome, clinical significance,
repeatsd measures and residual gain
reliable change~ dropout status
scores. Some significant d:ijferencu
1. ~ Y:u.nm, DcprtImeiDt of~. Bb:r.
mI ModI.cIIJ CcaIar IIICl Albert BiDI1IIiIt CoDep otMedldM;
kra:uy D. 8drm, ~ of~. Nn Scbool

1hIiveoUJ md J):param:IIIr ofPlyc:blltry.Beth r...I Nadical

CeaIer; Ua Wil1DIr SamIta& 'J)eputmeal of

...,.10&7.
tJI..,..

Lcq IIIIDd UalWIIIIty III Broo:ilya IIIId J)epl1....

c:hi.aII7. DedI J.uIIll ModlctIl CeafIIr, md AaIo'ld WlDItoD.
, DepIt_ of~. BedlI1dol Wtdic:al CcaIar - '

AlbeIt IIiDIIIda ColIIp ol ~

The ~ .... I1IJIPOIlId fa pIlt by . . . . fRIm tho
Natblal &a1ItulII of MIIIUI Health MIUO'l46. It WII pD
IeQII!Id It Ibo amJeIlIIOCtID& tIC . . Soc:IetJ fat ~
~ s.m. BcbIrI, CalIfcm.la. JUlIe 2002.
. W,,1riIh 10 IICblowledp tho ~ of BID'DaId S.
GOI'DllIIlIIIId II 0Uf .l..-mh _ _ III IIdditioa. _ waa1d

&leo JIb to thaDt our co,pkI~onllllpllliscD Jt.I..

l1Dza TI1I1lIif. BIIDbe1h Ochoa. ad PI:JIly ScIm1coe, our
abcrt-tmm dyMmic lUJ*Viicn 10&'01II6 PollIck. t.Iie BaBtf.
ad MlcbMl LIIkID, .. well .. aD tile ~ nd pati.eI1II
wbO puticipatIld.
~ cooc:cndl IhiI erlkkl sbov14 be lid
dnaId. to J. ChJlItopber M1II'III. DIIh ~ Medical Ceater.
}lim AftIl1I8 at J6th SU'C!Ct. New YQI'k, NY 10003. BmaD:
jcmBreIl.~.org

532

Mucb has been written about the limited C'.:CO

lop;al validity of tl1c rcscaroh on lllIIllJ empiri
ca11y supported tr:eabXlents that have been tested
largely on pa1ienta with very circumscribed di&g..
DDStic profiles and p.d:m.arlly Axis I conditiORllIaI_...,
(d. Elliott. 1998). In their cridcalJeVicw of 1m
domized clinical trial 8'bld1es, Weshm and MOl'
Iieon (2O(1) found that the czclualcm l'8Ir:8 of
patients who presented with multiple dlagDlJiIC&
lypically nmgcd from ~ 10 7096. Tho vaal
JDl90dty of patioots that aedr t.reatmeat in our
mental health cliDica Ol' pri'IIdC pradiccs, h0w
ever, do present with ~Ic diagD.oses with
estimates of comorbidity nmging from 4ft IQ
709& (see Kculer ct aL, 1994). 'lb1l8. 1he eD:IDt to
Which me peat body of peychodletapy reaearcb
conducted on sinJly diagnosed. patienta is rele
vant 10 practice in ftl&l-world settiDga is arguable.
In contrast., the empiricallitt:rat.ure on Iho treat
ment of>personaUty diIotden (Bate:lnaJl cl PoD- ,
18)'. 2000; Crits-Christoph. 1998; Perry, L.iDs
iardi, &; IIDhi, 1999; Piper I: .royce, 2001; Shea,.
1993), which is growing but remains limited in

----

~Theory.~""", T....
111)0. Val. 41. /110, 4. 6ll-64S

0201O~I'I~A~
003~IIIISI1.OI)
1lOI 1!I,IOl7hoIlMII7S

DROPOUT AND THERAPEUTIC ALLIANCE:

A META-ANALYSIS OF ADULT INDIVIDUAL

PSYCHOTHERAPY

JENNIE SHARF

LOUIS H. PRIMAVERA

Pace University Counseling Center

Touro College

MARC J. DIENER
Argosy University, Washington DC

This meta-analytic review of 11 studies

examined the relationship between psy
chotherapy dropout and therapeutic
alliance in adult individual psychother
apy. Results of the meta-analysis dem
onstrate a moderately strong relation
ship between psychotherapy dropout
and therapeutic alliance (d = .55).
Findings indicate that clients with
weake.r therapeutic alliance are more
likely to drop out of psychotherapy. The
meta-analysis included a total of 1,301
participants, with an average of 118
participants per study, a standard devi
ation of 115 participants, and a range
from 20 to 451 participants per study.

-----.,"'-_.
Jennie Shad. Pace Univemty Counsetinl CmlIU. Pace
UIIi~ Louis H. Primavera. Oraduate SChool of Psychol
ogy IUld Sdlool of Hea1tI1 S~. Touro College; and Man;,
1, Diener. CUnICll PsycbolollY Pro&wn. Argosy University.
Wuhingtoo DC.

'Ibis paper is balled in pan. OQ tho Derner luIitute of

Mvmced hy<:~ Studies, Adelphi Uoivcnitj doctoral
~ of Jamio SbIrf. An utI.iec vaaion of Ihla llUdy
was ~ lit tho 8.lUIull meetilll oflhe A.mericuI ~
lop AssociItIoa. BosIon. Aupst 2008. Th6 IlUI.bon atlI
graWvl to tbe Editor. Dr, CIwIes Gelso. mil the lIlIOQymoll$
reviewm of this maDIlSCript for thdt be1pl\.I1 oomJIIOnll &lid
SUggWlODS, We thank Dr, tUbn JoI:wIIson. Dr. William
Piper. and ClIrIos SiemI for ,proYidiIll additioQ.t.\ daIa from
several od&inal slUdies. We also thank Dr. ~ Shick
TryoI! fOt her helpful roc:ommen<laliOIlJ, We are alto aweM
to Dr. Micbacl Boremmo for his swistical consultation.
ComspolldeDCe reptll thiI article should be ~
to lennie SIIad', PhD. Pace Univusity Counseling CaIre!", 156
WUllam S~. 12t1l Floor. New York, NY 10038. 8-mall:
jsharfegmail.com

Exploratory analyses were conducted to

detennine the influence of varitlbles
moderating the relationship between
alliance and dropout. Client educa
tional history, treatment length. and
treatment setting were found to moder
ate the relationship between aUiance
and dropout. Studies with a larger per
centage of clients who completed high
school or higher demonstrated weaker
relationships between alliance and
dropout. Studies with lengthier treat
ments demonstrated stronger relation
ships between alliance and dropout.
Inpatient settings demonstrated signifi
cantly larger effects than both counsel
ing centers and research clinics. No
significant differences were found be
tween client-rated. therapist-rated. and
obse'n'erlstaf/-rated aUiance. Recom
mendations for clinicians and research
ers are discussed.
Keywords: psychotherapy dropout, pre
mature termination, meta-analysis, thera
peutic alliance, working alliance
Supplemental materials: http://dx.doi.orgl
1O.1037/aOO21175.supp
The most recent meta-analytic review of the
psychotherapy dropout literature (Wierzbicki &.
Pekarik. (993), found three client demographic

637

~~~
..-.----- ....

---------~

~~~~--.---

The Efficacy of Psychodynamic Psychotherapy

----------.-~---~-~-

Jonathan Shedler

empirical evidence supporrs rhe e..fjica.c.'l of I,sycnod),namic

(he.rapy Effecr .>i1;<1'> foy psyciwJ:rnamlc Ihercrp:. are us
largt ,2, fhou ~eporud f(lr Qrlu!r Int'rapies thar hawt iJeen
O0'li\llIJ), promoted I1S "l'mpiricaii}, supporled" arid ;(lvi
detlC(! based. .. [,1 addirioll. par,e"J, who rece;"e psycilOdy
mImir !hfl'tJjJY mair.lOtn rhempeunc golns GIld appf!ar to

co,;:i'lil'; I,) impro\c af:rr rtcu!l7lefJI c'1ds, Finally. nonpsy

d:, ,d,",unur /Iu:. aplt'.l '1iC<) be eJ!e:i:I;n: In pari becaL/Je rite
/II'm? skilled practiriol7ers wilile ichnh?Uer that have lOll-ii
b~'.~J\ ('elllral II' psycllOd) numic :h~o,) and practice, The
pprnpfiorl :hat pS}'fi!odlnamic {Ippmacl:es lack empincal
H<pport

does

110r

accord with aI'ai/able scientlfk eVidence

(m.i moy reffect sl!iecli"e disuf"1irwrioll (~f reJearcn find

ing5,

psyc!lOtherapy

procesli.

psychol!nal}'~is,

OU:COffie,

p~ycho'herap:r

psychorlyn&mit thetapy, meta

1lJ'l81ysi~

hc::re ~ a bchcf in ~ome quanel'" that psychodynilmlc

conctpttl and trel!tments lack empirical sUPPOl'l Qr
thaI scientific eviden.;;e shows that other fonus of
treatment are more effective. The belief appears Ie have
taken on l life of it~ own, A.cw:lcmiclan!> repeal it to one
anoilier, as do health care admini5traton, as do heaith care
policymakers. Wilh !"..arh ri\p~tltion. lts apparent credibility
grows, At some pomt. there seems h~tle lleed to q\lestion or
reviSll II oocaus: 'evef'!.one" knows Ii [() be S0,

The ~cjentifi(' evd~n~e te:h a different story: COMld

erable f':,:~c;!lJ..:h ~UPPQ:1S me efficacy and effectiveness of
!"sych()dynamic tl.C:13py. Thl' di..,crepancy between percep
tiolls and evidence may be due. in pari. to biaseG in the
dissemination oJ research findings, One potential source of
bias lS a lmgenng distaste in the menial health profe~g:on.s
for paSl psychoanalyu(' arrogance and authority, In decades
Pil.,t, American psychoaoalysis ...'as dl)minnted b,li hierar
cillcal medicai eSI!lbli~hment L'lat demed training 10 non

MDs and adopted a dismissive StSll,;e toward resear<.:n, This

stfJ.llt'e did nOI win fnends in academic circles, When em
pirical fmdjng~ emcfSoo lhal 9uppr,rred nonpsychodynami;;
tn:atme:IIS. many academicians greeted chern enthusiasti
cally and were eager to dis(,u~s and d:i~&eminate them,
When tomplIi.cal e',ideTlce Fiupported psychodynamic can
:;;e;;t~ and treatments. it was often overlooked,
This article bnngs IOgether nndillgs trom several em
plrical literatures tilat bear on the efficacy of psychooy

Univer..iry of Coiorado Denver School of Muii( llIe

over time, Finally, I con~ider eVldence lhllt Ilc,r,psy::i'wd'

namic therapies may be effecthe in part becau"C th; rr.');
~killed prllCtitionere utiliz.e interverHiol'lS thtll hllve k1
been central to psyclwdynamic theory and

Psychodynamic Technique
Ps),chodynanllc or psychoanalytic psp::holh"f'af)Y' ,
tvs to a range of treatments based on
concepts and method~ ,bal involve les!.
and may be considerably briefer than p,ydlO!!naly'
proper, Ses~ion frequenc)' is typically once rof tWICC pc
week, and the rreatmenl may be either time limited -::Ir ('IX
ended. The es~ence ofpsychodynarnic therllpy i~ ~xplorll.
those aspects of s.elf that are l10t funy knowa, especi<il~j
they lI.Te manifested !uld l"oiemially mfluenced in the dw
apy relationship.
Undergraduate te,'ttoooks too often equate
alytic 01 psychodynamic tnerapies with some 01 the mo,
outlllr.di.<ih and inacceBsible spl!culahons mad!; b~ Slgmw
Freud roughly a century ago, rarely presentinl'; m3.in.~tre:.,
psychodynamic concepts as un(\uStooc! and pn), l:ccd I
day, Such presentalions. along with caricatured dcpictif.>'
in The popular medin, hiIVe contrIbuted to \Vide~rl'flad mi
understanding of psychodynamic treatment (ft)f \;i~..;u%i
of how clinical psychoan::llyslS is represented an j micre,
resenteci in undergraduate curricula, see Borm,\l<in, i 98
1995: Hansell, 2005; Redmond & Shulman, 2()j)X). ro lid
dispel pOSSible myths and facilitate greater .mUI:'!stdIH,h::,
of psychodynamic practice. in tilis ;ccuon I :e', I~'.\:"
features of contemporary psychodynamic technique,
Blagy. and Hilscnroth (2000) conducted d ~earc:1
the PsycLit datllba.'\e to identify empirical ~ludic, ;h,tf
pared thE' process and techni:jue of munua\lz~d pydt(),J.
l1amic therapy with tha, of marlU:lllzed
therapy (CBT). Se\<en features reliably
chodynamic therapy from other therupies, 8 dcr(,,);'fl'ntd L
empirical examination of actual session recordill", an
I IhrlOk MIITK HHsenfOlh fo! his ex!en~i'.'e <xmlnbul,cn) to ;Inr, Jf1~,
Mm Dten~ fer pto'l'iding lOrne; or tho inrOmlill!(If\ tepo!1ed t.r., Ro,'
Fe'M$lelr., O\M Gsbbar<! Michlel Kmon. Kenneth Le'j, ~"{ J M, \\
lilms.l{ohen Michel!, G~orgc Smc~er. anll 1\():>el"l Wa:le:',"'" fe" I"
C:)ffimems on draftS of tl1c lIftlcle; .nd
P5)'c~.odynQm:c Rc~8rch LiiI$'UY

port.

evidence thaI patients \\hl! re(,(;l>e ps~chodynamic therapy

1101 onlv maimain thcmpeutic gain, hut :'of'ltinut to imrrove

Plae~. Adt~r.,

98

j)fln:t.;;(',

Distinctive features of

feature~ of
pS~i\:'h.0dym\lmc therapy. I next r~\lell emp:rical evidence
for the effi~(lcy of p,ychodynsl111<' treatmenl. including

namic treatmenL I tirst Clutline the dbtmc:ivli!

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wi-d!,,1' ,~nd

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i.;tJ!'!:"'l. P

JOrl.thar Shocl&r, Depattl'l'lel1l of P.ychi~try, U"VC'''I, nt C ,\I,

,ado D",,,' .,,. School of Medicine, M.il SlOp

, I ,~"" 'he

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CQ ~OQL$, &-0'1 ..1 \(>II.!h,~rihhlldlt, riC,n

(Urn, 1,,}chorJlIltrrlc ~r.d,nl)'c~odwlllmi( m'~,dl'''!i~l:

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Article

Randomized, Controlled Trial of the Effectiveness

of Short-Term Dynamic Psychotherapy and Cognitive

Therapy for Cluster C Personality Disorders,

Martin Svartberg, M.D., Ph.D.

Tore C. Stiles, Ph.D.

Chanl!!~mptom~ (
v""
Wh9
.

ObjedMH This SlUdy compali!d the d period. Significant

fectMnas of short-term dynamk: psych0
dlstnID_~weAJ
forS
therapy and cupitive thr:rapy for outpa ItOUP Of jiitlirili
tiI!&iM DIOFRifJ'nf
tients wtth duster C peflIOnality disorders.
'ilYi'Jiiil1c;
LUinOtlt!0~e

meral)'

patients. DiSp
e

MeIhod: Patients (N=50) who met the qnltfw

dwr;enca rnjntliifQup chanees, no stacriteria Ivr one or more duster C pers0n
ality disorders and not for any OI:tIer per tfstIiairy SiiflifIWrt CIJffeteiiQ; bfifWi!n
011' IrRIllMerm dYMiMlc p;ytnotMlipy
sDnallty disorders were randomly as
'.IOUp
ana WifidMllt'IMfJt puIS I"m
slsned to m:elve 40 W"~
of
short-term dy"am1c PlYotberapy or tWf'id on Iny MamA! Ib, itiY' tirinl pi;'
coanldvethr:ra"W. The riA tbtIImon axfs -'nOil I . , . , II tel tidtiiiem;5496ofChe
I dlSUilSift In tne Pi\lent IVOUP were an. short-term dynamic psychotherapy pa
Iety and depression dtasnoses. Therapists tients and 4~ of the COIfIltIIfe therapy
_re ecperienccd. fulf.tfme dlnlclans and patient:. had reawered symptomatkJlIJv.
_re rect!l\IIfII manllal~~rvf. whereas approximately 40'1tt of the pa
tients in both groups had rt!!Coveted In
sfon. Outcome val'blbles Indulled symp
tom distress. InterperSonal problems, and terms of interpersonal prOblem,4uld
core personality pathDlolY. Measurea sonallty funcIionlnc.

Michael H. Seltzer. Ph.D.

_*1)1

".........

*'

per..

wen! administered

repeltedJy dunns and

after t.rbtment. anef chance was assessed

1ons!Wdlnally by means of growth model

endualons: Both short-term dynamic

p$ychoth4tFapy and "lsnltl\'o theltlpy

have I place In the treatment of patienf5

Results: The owraIr petIettt II'CUJ) showed,

on average, statlstlcallv sil'1lf1cal'lt Im
PltM!l'nenb on measures &tvrlna treat
ment and also dutlna .. 2.yqr follow-up

with duster C personality dlsordm. How

ever, fIIctors other than treatment modal-

Ity may discriminate better between suc

cessful and poor outcomes. SUch fadol'l

should be explon:d In future studies..

I,... pro(:Hurcs.:

~J ~~ 1'1t1fUJ1J

The

cluster C dIaordm 11m the DIOtt pnmlent penon

a.Uty cUaolderl in the gIl'l8l'8l population (1) (one of 10 In
dMduala) and In~ cIbl1c popula!ns tID (mom
thm one of tWo ~Mbfi!diiiiI the presence of InY
cluaterC pmonaUtydiaorder. bmrlahly uaoc1ated wfIb
poorer outcomes In the treatment of ala I diaordera (3-5).

In JJtbt of theae find1. it pualfng to flnd IUch B

.1audtt of mntmlJed tri!l& !UJl!lmns the e1I'ectMmeu of
IndIYlduat ~ in thIt popqlltlpn, ~ng1he
handful of stud1eI that have been condw:led. only one (6)
canbe~ aa aWldomlzed,coD~
dfically dealped to
the course or these dfaordera
dwiDl and atter treiiDiilit. In thai
8I' patients with
~
Cdiaorden (7O'IL) mowed.rgom..
cant and equtvalent tmpto'll'llmllnt on mea8'llI'ft of ~
and 8Oda1funct:lo1dDg after 40aeulons oftwo forms of dy
namic ptycbotbe.rapy. Furthcnnine, treated patientI did
alpIfbntly better than wait-llat coUlparl8on 8'1lhjecta,
and pins WfIre malntalned. at 1.5-yiu tanow-up. In two

.way

cmeter

810

1_

htIp:llo}fl.P'J'IIChiGtI)/onIlne.013

addJtlonlll zandomlilled, controlled trlala, data fo.r sub

groups ofpatlenD With predomlnantly cluster C dlaon:1em

were analyzed separately witbln IarJer 1dals designed to

study major depMsaton (S, 4). The ItUdies found tbat pa

dt'.Dtll with ptmIODIl1tydisordm responded equaDywell to

InteIperaonal paychotherapy md cognlttve beba:v.lor ther

SPJ (S) and equallyWBll to psychody.namlc-lntelpelloDal
therapy and cognltiw behaviorthem.py Pinall}'; In one
uncontrolled study, sa patient. with obseutve-compul. . .amt a'ilOMint penmnaJity disorders treated with timelIm1ted aupponi"..ezp.resslw therapy demonstrated aign1flcant average chances on dIagnoetic meuw:ea and on
mea&\1IeI of d:ImuI. ~ problems, andpet'l!ODo
alltyfuDCdoning tn.
1'be presentatudymcmda tbcatudybyWimtonet al. (6)

by eu.miDing the effects of "O-session. ahortterm ely

JWI1k psythother:apy apeciflcally destped forpenonality

problelJll (8) and comparing thoae dec:1:B not with m

other form ~ d}'DlDlfc tbexapybut with an al1amame ap

(41.

' {

Opb ,

11m} Psyddotry 161:5, May:1.004

~
~ !",,~.

'

Elii' Child AdaIeK Psychiatry (;!OO7)

16:tS7-167..DOt lG.l00;/sOO781-006-OS84x

Judith TroweU
nan Joffe
jesse Campbell
Carmen Oemente
Fredrik Almqvist
Mika Soininen
UUa Koskenranta-Aalto
Shena Weintraub
Gerasimos Kolaitis
Vlassis Tomans
Dimitris Anastasopoulos
Kate Grayson
Jacqueline Barnes
John TIIlantis
Accepted: 14 October 2006
Published online: 1 January 2007
Original lead
(deceased ,.

r~(:her:

Prof 158Y l<olvin

I. TroweU. MBBS. OCR, DPM. FRCPsych

(~)

Pro(mor or Child Mmtal HWlb

West Midlands NIMHEICSIP
Honorary Consultant Child &
Adoll!SCml Psychiatrist
Tavistock Clinic
120 Beiliu Lane
London NW3 5811, UK
TeJ.: 01701 652205 (UK)
.Mall: judilh.lrowellj.csnet.co.uk

I. roffe, MRCPsycn
Hertfordabire Plrlner$hip NHS Trust.
<:hOd & Family Clinic:
MarloweB Health Centre
Heme! Hempllead UP1 HIE. UK

J. Campbdl
Tavislock Clink
120 Bel&i%e Lane
London NW3 5BA, UK
C. Clemente. MRCPsych
Royal Free Hampstead NtiS Trust
Department of Child a
Adolei(ftlI Psychiatry
Iloyal Free Hospital
Pond Street
London NW3 3DP. UK
F. A1mqvist. MD. PhD
M. Soininen. MD
U. Koskenranta-AILIto, MD
S. Weintraub. MA
Department of Child Psychiatry
The Uospital ror Children & Adola;cents.
t'laculty of Medicine
University of Helsinki
Lastenlinnatie 2
00250 HelsinkI. Finland

ORIGINAL CONTRIBUTION

Childhood depression: a place for

psychotherapy
An outcome study comparing Individual psychodynamic
psychotherapy and family therapy

II Abstract Background

Although considered clinically

effective, there is little systematic
research confirming the use of
Individual Psychodynamic Psy
chotherapy or Family Therapy as
treatments for depression in chil
dren and young adolescents. Aims
A clinical trial assessed the effec
tiveness of these two forms of
psychotherapy in treating moder
ate and severe depression in this
age group. Methods A randomised
control trial was conducted with 72
patients aged 9-15 years allocated
to one of two treatment groups.
Results Significant reductions in
G. I\oiaitis, MD . D. Anastasopoulos. MD
J. Tsianti5. MD, DPM. FRCPsych
Departrnmt of ChUd Psychiatry.
Agbia Sophia Children's Hospital
Athens Univec$ity Medkal School
Thivon & Lewdlu
115 21 Athens. Greece
V. Tamara&. MD
Department of Psychiatry.
Eginition Hospital
Athen$ University Medical S.::hool
72 Vas. Sophil.$ Av
115 28 Atheru. Greece

K. Grayson. BA. Ms'::. FRSS

Statistics By Design
6 Soudumpton Close, Blackw.ter

Camberiy. Surrey G UI7 OHB. UK

J. Barnes. SSe. MSc, PhD

IMUtule fOf the Study or Children. Families
and Social Issues, 8lrkbeck
Univmity of London
7 Bedford Square WCIS 3RA, UK

disorder rates were seen lor both

Individual Therapy and Family
Therapy. A total of74.3% of cases
were no longer clinically depressed
following Individual Therapy and
75.7% of cases were no longer
clinically depressed following
Family Therapy. This induded
cases of Dysthymia and "Double
Depression" (co-existing Major
Depressive Disorder and Dysthy
mia). There was also an overall
reduction in co-morbid conditions
across the study. The changes in
both treatment groups were per
sistent and there was ongoing
improvement. At follow up six
months after treatment had ended.
100% of cases in the individual
Therapy group, and 81 % of cases in
the Family Therapy group were no
longer clinically depressed. Con
clusions This study provides evi
dence supporting the use oifocused
forms of both Individual Psycho
dynamic Therapy and Family
Therapy for moderate to severe
depression in children and young
adolescents.
II Key word5 treatment

childhood depression ..
individual psychotherapy
family therapy
II(
?w

.....

.-.

~~~m;raxm

PubliJhecl. 0IAIiNt in WiIay ~ (\IfWW~.wlle,a:cm). DOl: lO.l002/c:pp.530

Who .Can Benefit from Time

Limited Dynamic Psychotherapy?
A Study of Psychiattic Outpatients
with Pers~nality Disorders
Do Vi:rmal's,1- Ja~ues p. B.ub~S Kristina NO~l
Barbro Thormlhlen..',2. Robert Gallop,' Amdka

Lindgrent and Robert M. Wehuy"b1

1 Deportmmt

of Cli:nictIl

NtIUOSCielu:e.

StcHtm, ~

Institufd, Stod:holm, Srmien

.

'I. Deportmmt of N~, DlvtJifm oj ~. lCImJIi,.. Ins:titJdtlt,

SfJiholm, S11Jttlm

Deptfrtmfmf rfp;ydd4try, Utriwr5ifyo{PermsylwnfR. PhilRdelphilf, PA. USA

"Dcpa,tmentafSrmisticB, WeslChesmUnl.r1ersi.ly, WfstChesta,PldWelpIdll,

PA, USA ,

Introduction: This atad.y examined wbethe:r meuures of P'enonMtty

Disorder (PO) from the Dlap.oadc and S~ Manual of MenJBl
.. Di80tder IV, psydlodynamk character, psydWoslail mindednas,
:lnterperaonal pattun. and' penonallly trafta predidH tlUtDum.t
oub:ome for PO patients. Method: ConIecutive 1'D patient. were nn-
domly assIped to manua1.lzed tl.m.e-lI.adted $Upporti~l.ve.
PfYChotherapy (SSP; 11-76) or l\otI.~d opetHnded. commu- .
alty delivered payehodynamk tredDl_t (CUPT; II - 80). SIpJfk:allt
pred1don were tested toptherhl orderfo exa.mmewbethe:r they mod
e:ratM or p:redided the :redu.c:tiOD 01 psyddatrlc IJYIIlPfOU\I (Symptom
Check 'Liart-9O).1lesults: In the~ patients with IDOntBeVete
levels ofPD d.i8cml~ 6iuUlbei~ve FD
ba~ s!'!
with
ofiDterDe1:sOna1 PrOblems
.evel8 Of IJP dOmilW'lCfJ were
alpiBcanfIy.relaled to bipet tate-of improvement In the CDPTtieat
m_t compued with SEP. CondVl!on: Due to the faC!tthat more severe
PO patients had ,lower rates of im~imt, Io~ ltutment
. ,:& iiiidii!p1 &Ii
Sp5~= jiiOplm'
im.pKt whether patientliOUld reeeift :tnanuaUzed or non-manual
~ttoPYfllit 0 200'1 John Wiley III: Sone; m.
.

c:r!!!d!!

POPUlA:O!'-

INTRODUCTION
tCt:!mepmdence CO: Do VImars, Deparimr:nt of Paych1atry,
Payldatii8ka D'lCtt/Cent.nanluaMt. I'itlfavlp 3-9, lC5 ~
NOr$bot& Swaden.

B-maD:bo.~
Part of the artlde WM ~kd at Itie annual ~ of the
Society for PaychoIberapy ~h (SPR) .In Senta 8Grbam,

CAt USA, In i m . "

Copyright., 200'1 Jo1m. Wiley at Sons, Ltd.

Demands for time-limited and m.anuaBzed. evi

d~ psychotherapy (BBP) are.increasing as
a means to use Hmib!d. l'eIIOl1Ite6 more effedively

and to increase the UkelIhood. that patien1s will

receive reasonable and effective treatment ~

Novotny, Ie ThoinpsonBrenner, 2(04)., BBP guide
linea usually target spedflc.. relatively ham.oge
DeoUS axis 1 psychiatric DIagn~ and Statfstical

.-. fIWlll!Y

i & InferSciel1Ce
. . . . .ne ......... uu.

fU ... '