AN OPEN DOOR REVIEW OF CLINICAL, CONCEPTUAL, PROCESS AND OUTCOME RESEARCH IN PSYCHOANALYSIS IV
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Project TR-EAT: A Multicenter Study of Inpatient Psychodynamic Treatment of Eating Disorders in Germany
Kächele H, Kordy H, Richard M & Studiengruppe Mz-Ess (2001) Therapy amount and outcome of inpatient psychodynamic psychotherapy of eating disorders. Results of a multi center study across Germany. Psychotherapy Research 11: 239-257
In spite of a growing number of studies about the efficacy of psychotherapy in eating disorders, the knowledge about the optimal treatment intensity and duration is sparse. This study investigates (1) factors that determine length of treatment and (2) the effect of treatment duration, and other factors, on treatment outcome. It is a multicenter observational study. The symptomatic status of 1171 patients with an eating disorder was observed for 2.5 years after the beginning of treatment in one of the 43 participating clinics. Length of treatment and treatment outcome was modeled using hierarchical linear models and logistic regression. To control for possible confounding factors, propensity score adjustment was used to compare long and short treatment. At 2.5 year follow-up, 33% of Anorexia patients and 25% of the Bulimia patients were symptom free. Length of treatment varied considerably between and within treatment centers and was related to patient characteristics to a very small degree. Length of treatment in interaction with other patient characteristics had an effect on treatment outcome, treatment intensity was not related to outcome.
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The Berlin III Study (A, B & C): A multi-centre study on psychoanalytic oriented treatments
Rudolf, G. (1991). Free University of Berlin: Berlin Psychotherapy Study. In L. Beutler & M. Crago (Eds.), Psychotherapy Research. An International Review of Programmatic Studies. Washington: American Psychological Association.
Rudolf, G., Manz, R., & Ori, C. (1994). Ergebnisse der psychoanalytischen Therapien. Zsch Psychosom Med, 40, 25-40.
Rudolf, G., & Manz, R. (1993). Zur prognostischen Bedeutung der therapeutischen Arbeitsbeziehung aus der Perspektive von Patienten und Therapeuten. PPmP, Psychother. Psychosom. med. Psychol., 43, 193-199.
This was one of the successful products of the research program conducted by the Ministry of Technology (BMFT) in the early eighties. The Berlin III Study was a field study collecting systematic data from patients in out-patient and in-patient psychoanalytic oriented treatments.
Within a naturalistic design, 44 psychoanalytic treated patients were examined with regard to qualitative and quantitative indicators of outcome. The results were compared to 56 outpatient psychodynamic therapies and 164 inpatient dynamic treatments. A comparison of symptoms, diagnoses and motivations before therapy led to the conclusion that the patient groups in these studies were different at the outset. It was concluded that randomisation to these treatments would not be an adequate strategy. Using various criteria of outcome it was demonstrated that psychoanalytically treated patients improve quite markedly and to a larger extent than out-patients or inpatients treated with psychodynamic therapy. Three studies are reported. The first demonstrates that patients in outpatient psychoanalytic therapy showed improvement in 96% of cases, compared to about 64% of inpatients also in psychoanalytic therapy who showed improvements. Patients who did not finish therapy fared worst in long term follow-up. In the second study, 44 psychoanalytically treated patients were followed. Anxiety and other mood disorder symptoms showed largest effect sizes. In the third study, the therapist perspective on the working alliance was found to be the best predictor of outcome.
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The Heidelberg Study (A & B): The Heidelberg Psychosomatic Clinic Study – a naturalistic prospective outcome and follow-up study
Rad, v M., Senf, W., Bräutigam, W. (1998). Psychotherapie und Psychoanalyse in der Krankenversorgung: Ergebnisse des Heidelberger Katamnesenprojektes. Psychotherapie Psychosomatik medizinische Psycholologie 48, 88-100
In the "Heidelberg Long-term Psychotherapy Follow-up Project", a naturalistic study design, all types of treatment were included that had been performed at the Psychosomatic Clinic of the University of Heidelberg for a certain period (combined inpatient and outpatient individual and group therapy, as well as outpatient dynamic psychotherapy and psychoanalysis). A specific strength of this project is that three to five individual therapy goals were predetermined for each patient before starting the treatment (Goal Attainment Scaling). After the end of therapy and at the time of follow-up (3.5 years later), attainment of these goals was assessed by an independent rater. A total of 208 patients were examined, among them 36 patient in psychoanalysis (three times as week) who were evaluated according to their diagnosis (neurotic, functional or psychosomatic disorders) and the kind of treatment. Psychoanalysis had superior outcome to psychotherapy but the difference diminished by follow up (four years). Goal Attainment Scaling also highlighted the efficacy of psychoanalysis. A spin-off investigation demonstrated a powerful dose-response relationship between treatment and outcome.
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The Heidelberg Study (C): Long-term outcome of out-patient psychoanalytic psychotherapies and psychoanalyses: a study of 53 follow-up interviews
Heuft, G., Seibuechler-Engec, H., Taschke, M., Senf, W. (1996). Langzeitoutcome ambulanter psychoanalytischer Psychotherapien und Psychoanalysen: eine textinhalts-analytische Untersuchung von 53 Katamneseinterviews. Forum der Psychoanalyse: Zeitschrift fuer Klinische Theorie und Praxis, 12, 342-355
A further paper from the Heidelberg group was a contribution to the development of new strategies for follow-up methodology relying on qualitative text analytic strategies and individualised treatment goals. The attainment of individualised treatment goals were compared for psychoanalytic (N=33) and psychoanalytically oriented psychotherapy (N=33) treatments at least two years after termination on the basis of text analysis of an interview. Overall, 72% of patients in analysis and 56% of patients in psychotherapy were rated as having achieved their goals at 2-year follow-up.
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The Heidelberg-Berlin Study: The DGPT Practice Study on long term psychoanalytic therapy
Rudolf G, Grande T, Dilg R, Jakobsen T, Keller W, Oberbracht C, Pauli-Magnus C, Stehle S & Wilke S (2002) Structural Changes in Psychoanalytic Therapies - The Heidelberg-Berlin Study on Long-Term Psychoanalytic Therapies (PAL). in: Leuzinger-Bohleber, M & Target, M(eds) Outcomes of Psychoanalytic Treatment – Perspectives for Therapists and Researchers. Whurr, London, 201-222.
Grande T, Dilg R, Jakobson T, Keller W, Krawietz B, Langer M, Oberbracht C, Stehle S, Stennes M & Rudolf G (2009) Structural change as a predictor of long-term follow-up outcome. Psychotherapy Research 19 (3): 344-357.
This study has been launched by the membership of the DGPT, a German Psychoanalytic Umbrella Organisation. Two samples of 36 patients with severe disturbance, treated either with psychoanalysis (3-4 times a week) or 1-2 times per week face to face psychotherapy, are currently being studied by a group of investigators who are not involved in the treatment. Every three months an interview is performed and systematic evaluations of the development of symptomatic and structural change are recorded. The study uses the Operational Psychodynamic Diagnosis tool as the major assessment instrument for measuring structural change and the technique of goal attainment using a Heidelberg version of Stiles' APES.
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The Menninger Psychotherapy Research Project (PRP)
Kernberg, O., Burstein, E. D., Coyne, L., Applebaum, A., Horwitz, L., & Voth, H. (1972). Psychotherapy and psychoanalysis -The final report of the Menninger Foundation's Psychotherapy Research Project. Bulletin of the Menninger Clinic, 36, 1-275.
Wallerstein, R. S. (1986). Forty-two lives in treatment: A study of psychoanalysis and psychotherapy. New York: Guildford Press.
The PRP was launched in the 1950s and it was the first prospective study of long-term psychoanalytic psychotherapy in the United States (Kernberg et al., 1972). Forty two patients originally assigned to expressive or supportive therapies tended to have various combinations of both treatments across the three decades of the study. The investigation which has been reported in a number of books and many papers was concluded with Robert Wallerstein’s definitive report of the long-term follow up, the history of these patients spanning 30 years (Wallerstein, 1986). The sample was too small to permit adequate analysis of the large number of measures and treatment patterns. The findings indicate that some severely personality disordered patients may require psychoanalytic therapy if they are to show significant improvement.
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The Stockholm Outcome of Psychotherapy and Psychoanalysis (STOPP) Study
Sandell, R., Blomberg, J., Lazar, A., Carlsson, J., Broberg, J., & Rand, H. (2000). Varieties of long¬term outcome among patients in psychoanalysis and long-term psychotherapy: a review of findings in the Stockholm outcome of psychoanalysis and psychotherapy project (STOPP). International Journal of Psychoanalysis, 81 (5), 921-943.
This study makes use of an innovative 3-wave panel survey design to study 430 patients at various stages of psychoanalysis or psychotherapy (before, during, or after therapy). Treatment modality was self-selected and stage in treatment was considered to be a randomised factor. An extensive battery of measures was used including standardized self-report instruments (SCL-90, SAS, SOCS), specialized questionnaires addressing the patient’s family, health, work, and general condition, and a therapeutic identity questionnaire completed by the therapists. The psychotherapy and psychoanalysis groups started out at similar levels of psychopathology and were both in the non-clinical range by the end of therapy. However, psychoanalytic patients continued to improve while psychotherapy patients did not. Older therapists achieved better outcome than younger ones, though, the second youngest, not the youngest therapists did worst. Therapists who endorsed items that clustered into “supportive¬interpersonal†or “supportive-intuitiveâ€groups had more success than those in the “classical†cluster, irrespective of whether they were treating patients in psychoanalysis or psychotherapy. “Classical†therapists did particularly poorly when practicing psychotherapy. This study has fascinating results, though the methodology and data analysis are still new and of uncertain validity. HLM analyses may resolve some of these problems.
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