Blog

Lilliengren, P., Johansson, R., Lindqvist, K., Mechler, J., & Andersson, G. (2016). Efficacy of experiential dynamic therapy for psychiatric conditions: A meta-analysis of randomized controlled trials. Psychotherapy, 53(1), 90-104.

There is growing research support for the efficacy of short-term psychodynamic psychotherapies to treat common mental health problems. A subtype of short-term psychodynamic psychotherapies is called experiential-dynamic therapy (EDT), which goes by a number of different names such as Fosha’s accelerated experiential-dynamic psychotherapy, and McCullough’s affect phobia therapy. A fundamental assumption of EDT is that conditions like depression, anxiety and personality disorders are by-products of an individual’s attempts to regulate strong emotions associated with adverse experiences in attachment relationships during childhood. When the attachment system and associated affects are re-awakened in current relationships, the individual may engage in maladaptive coping that leads to difficulties in relationships. While EDTs may focus on helping patients to understand how their attachment difficulties lead to inhibitory affects and maladaptive defenses, the treatment favors interventions that facilitate direct experience of underlying emotions in the here and now of the therapy. In this meta-analysis, Lilliengren and colleagues reviewed 28 studies with 1,782 adult patients who had a mood, anxiety, personality, or mixed disorder. Compared to inactive controls, EDT showed a moderate and significant effect at post-treatment (range: d = .39 to .65) and at follow-up assessments (range: d = .26 to .62), with largest effects for depression and anxiety. When researchers compared EDT to cognitive-behavioral therapy (CBT) in five studies, there were no significant effects at post-treatment (d = .02, 95% CI: -.24, .28) or follow-up (d = .07, 95% CI: -.22, .36). The average quality of EDT studies was good. In fact, studies with larger samples, that used blind randomization and assessments, and appropriate statistical tests showed larger effects for EDT. Drop-out rates for EDT (16.3%) were similar to other treatments.

Practice Implications

Experiential-dynamic therapy (EDT), which is a variant of short-term psychodynamic psychotherapy, was more effective than no-treatment and just as effective as evidence-based treatments like CBT. The findings are similar to those reported in many comparative outcome studies in which any bona-fide psychotherapy is effective for many disorders. The average quality of the EDT studies was quite good, suggesting that the findings were reliable and valid, and perhaps underestimating the true effects of EDT.

Author email: peter.lilliengren@psychology.su.se

Levy, K.N., Kivity, Y., Johnson, B.N., & Gooch, C.V. (2018). Adult attachment as a predictor and moderator of psychotherapy outcome: A meta‐analysis. Journal of Clinical Psychology. Online first publication, DOI: 10.1002/jclp.22685.

Adult attachment refers to characteristic ways people manage their emotions and relationship styles. Securely attached individuals adaptively and flexibly experience emotions and they are able to give and receive love and support to others. Insecure attachment can be sub-categorized as avoidant or anxious attachment. Those who are anxiously attached tend to up-regulate their feelings so that they may feel easily overwhelmed, and they tend to be preoccupied with relationship loss. Those with avoidant attachment styles tend to down-regulate their emotions so that they have difficulty experiencing or expressing feelings, and they might dismiss the importance of relationships as a means of protecting themselves. John Bowlby, the founder of attachment theory, argued that psychotherapy had the potential to serve as a secure base from which individuals might explore themselves and relationships. He also described the therapist as a temporary attachment figure with which the patient might develop an emotional bond to promote change and for a corrective experience. In this meta-analysis, Levy and colleagues looked at whether attachment dimensions can change in psychotherapy and whether they can predict improvement in patient symptoms pre- to post-therapy. (A note on meta analysis. It is a method of systematically reviewing a research literature, combining the effect sizes in that literature, and summarizing these effects. Because meta analyses usually contain many studies, their results are much more reliable than the results of any single study, and so they provide the most solid basis for making practice recommendations). In this meta analysis, Levy and colleagues included 36 studies, totaling 3,158 clients. Higher client attachment security (or lower attachment insecurity) at the start of therapy was associated with better outcomes by post-treatment (r = 0.17, p < 0.001, 95% CI = [0.13, 0.22], k = 32). Also, greater improvement in attachment security (change in attachment security from pre- to post-treatment) predicted better outcomes (r = 0.16, p < 0.001, 95% CI = [0.07, 0.25], k = 15). When looked at separately, higher levels of either attachment anxiety or attachment avoidance were associated with poorer outcomes, and change in either type of attachment insecurity was associated with better outcomes. These effects appeared to be consistent regardless of the type of therapy (non-interpersonal vs interpersonal therapies).

Practice Implications

Although attachment insecurity is associated with poorer outcomes, change in attachment insecurity is possible with psychotherapy and this change is associated with better symptom outcomes. Therapists should expect longer and more challenging treatment with patients who are anxiously attached. Anxiously attached individuals may appear engaged early in therapy, but they are quick to anger, feel rejected, and become overwhelmed. Such individuals may benefit from help to contain their emotional experiences by repeating the treatment frame and increasing structure. They may also benefit from interpersonally-oriented therapy focused on reducing their preoccupation with relationship loss. Avoidantly attached individuals may appear aloof, but they may be easily overwhelmed by demands for closeness. Therapists may have to carefully balance the amount of interpersonal space or demands in treatment with these clients so that they remain in therapy.

Mallinckrodt, B. & Jeong, J. (2015). Meta-analysis of client attachment to therapist: Associations with working alliance and pretherapy attachment. Psychotherapy, 52, 134-139.

Attachment theory has become one of the most important conceptualizations of affect regulation and interpersonal relationships. John Bowlby and others suggested that attachment behaviour is hard wired so that infants can gain proximity to caregivers which is necessary for infant survival. Repeated interactions with caregivers coupled with the variety of caregiver responses (i.e., available, unavailable, or inconsistently available caregiving) lead to children developing internal working models of attachment. These models become the basis for attachment styles in adulthood. Attachment security in adults is associated with the ability to give and receive caring and love, and to adaptively regulate emotions. Attachment avoidance is associated with a tendency to dismiss relationships as important, and to downregulate emotional experiences. Attachment anxiety is associated with a preoccupation with relationships, and to upregulated emotional experiences. In a previous meta analysis, client general attachment security was modestly but significantly associated with higher levels of therapeutic alliance (r = .17). In another meta analysis, higher client general attachment anxiety was associated with poorer client outcomes (r = -.22). In this meta analysis, Mallinckrodt and Jeong assessed whether client attachment to the therapist was associated with client general attachment style and with the therapeutic alliance with the therapist. They included 13 studies representing 1051 client-therapist dyads. Client pre-therapy general attachment avoidance and anxiety were negatively associated with client-therapist attachment security, and the effects were modest but significant (r = -.12, r = -.13). Client-therapist attachment security was positively associated with therapeutic alliance (r = .76) and client-therapist attachment avoidance was negatively associated with therapeutic alliance (r = -.63), and these effects were large.

Practice Implications

Client pre-therapy attachment styles appear to have an impact on their attachment to the therapist. A client pre-therapy attachment style characterized by preoccupation with relationships and an over-emphasis on emotions (i.e., attachment anxiety) will likely lead to similar behaviors and preoccupations in the relationship with the therapist. Mallinckrodt and Jeong suggest that this might be the basis for transference-related phenomenon that therapists and clients experience in the therapeutic relationship. That is, client attachment anxiety and avoidance likely interfere with developing a secure attachment to the therapist. Further, client attachment avoidance with regard to the therapist may result in lower therapeutic alliance, which is key to achieve improved patient outcomes. Despite these challenges, therapists who can facilitate a secure psychotherapy attachment experience for their clients are more likely to see improvements in their clients’ functioning.

Author email: bmallinc@utk.edu

Kossowsky, J., Pfaltz, M., Schneider, S., Taeymans, J., Locher, C., & Gaab, J. (2013). The separation anxiety hypothesis of panic disorder: A meta-analysis. American Journal of Psychiatry, 170, 768-781.

The concept of separation anxiety is intimately tied to attachment theory. Problematic early attachments have negative consequences for adults’ ability to experience and internalize positive relationships which help to develop mental capacities to self sooth, tolerate anxiety, and modulate affect. Separation anxiety is the persistent, excessive, and developmentally inappropriate fear of separation from major attachment figures, like parents. It is one of the most frequently diagnosed childhood anxiety disorders, with a lifetime prevalence of 4.1% to 5.1%. If we knew that separation anxiety is truly related to or causes adult psychopathology, then we would have a better understanding of the development of adult mental disorders and greater reason to quickly and aggressively treat childhood separation anxiety. A meta analysis by Kossowsky and colleagues (2013) begins to address this relationship between separation anxiety and adult disorders. They looked at case-control, prospective, and retrospective studies comparing children with and without separation anxiety disorder with regard to future panic disorder, major depressive disorder, any anxiety disorder, and substance use disorders. The meta analysis included 25 studies of 14, 855 participants. Children with separation anxiety were 3.45 times more likely to develop a panic disorder later on; and 5 studies suggested that children with separation anxiety were 2.19 times more likely to develop future anxiety disorders. Childhood separation anxiety disorder did not increase the risk of future depressive disorders or of future substance use disorders. In a subsequent paper, Milrod and colleagues (2014) reviewed the literature on separation anxiety and psychotherapy outcomes of adult anxiety and mood disorders. Separation anxiety is associated with poor response to treatment of adult anxiety and mood disorders possibly because separation anxiety disrupts the therapeutic relationship. Separation anxiety also predicted non-response to antidepressant medications.

Practice Implications

As Kossowsky and colleagues (2013) indicate, it is possible that children suffering from separation anxiety disorder may be hindered early on in developing skills to help cope with anxiety and strong emotions. Nevertheless, the findings draw our attention to the importance of recognizing and treating separation anxiety as early as possible. A few psychological treatment studies show that disorder-specific parent-child cognitive behavioral therapy is successful in treating separation anxiety in children. For adults, poorer treatment response may reflect difficulty forming and maintaining attachments, including the therapeutic relationship. Milrod and colleagues (2014) suggest that psychotherapies that focus on relationships and separation anxiety by using the dyadic therapist-patient relationship to revisit earlier problematic parent-child relationships may benefit adults with separation anxiety.