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Keefe, J. R., McMain, S. F., McCarthy, K. S., Zilcha-Mano, S., Dinger, U., Sahin, Z., Graham, K., & Barber, J. P. (2019, December 5). A meta-analysis of psychodynamic treatments for borderline and Cluster C personality disorders. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

Personality disorders are common mental conditions affecting between 6.1% and 9.1% of the population. Having a comorbid personality disorder predicts a number of negative outcomes from psychotherapy including lower remission rates, greater resistance to therapy, and greater relapse after therapy. Psychodynamic therapies are one of two classes of therapy that have been repeatedly tested in clinical trials for personality disorders (the other being cognitive-behavioral therapies). Psychodynamic therapies aim to help patients improve their personality functioning, including attachment, mentalization, and maturity of defense mechanisms. Dynamic therapies for personality disorders include transference-focused therapy, affect-phobia therapy, mentalization based treatment, and good psychiatric management. In this meta-analysis, Keefe and colleagues systematically assessed whether psychodynamic therapy was as effective as other active treatments and more effective than no treatment. They also evaluated the quality of the studies. They found 16 randomized controlled studies of over 1100 patients that directly compared psychodynamic therapy to another therapy or to a control condition. Outcomes included personality disorder symptoms, suicidality, general symptoms, and drop-out rates. Overall, psychodynamic therapy was as effective as other therapies when it came to all of these outcomes, and the drop-out rates were equivalent. Psychodynamic therapy was more effective than no treatment for personality disorder symptoms (g = 0.63; 95% CI [0.87, 0.41], SE = 0.08, p = .002), suicidality (g = 0.67; 95% CI [1.13, 0.20], SE = 0.15, p = .020), and general symptoms (g = 0.38;95% CI [0.68, 0.08], SE = 0.13, p = .019). Average study quality was high, suggesting that one could be confident in the overall findings of this meta analysis.

Practice Implications

For all outcomes, psychodynamic therapies were as effective as other active treatments and more effective than no-treatment controls for borderline personality disorder and for mixed Cluster C disorders (dependent, avoidant, and obsessive-compulsive personality disorders). The authors concluded that psychodynamic therapies are effective in treating personality disorders like borderline personality disorder and those with Cluster C personality disorders.

Clients of Therapists Who Are Flexible Have Better Outcomes

Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. (2019). Adherence, flexibility, and outcome in psychodynamic treatment of depression. Journal of Counseling Psychology, 66(1), 94–103.

Psychodynamic and cognitive-behavioral (CB) treatments are quite different in how therapy is delivered, but both are equally effective for depression. Such findings suggest that various types of specific interventions can positively impact client outcomes. A possible mechanisms of therapeutic action is that effective therapists may be particularly responsive to their clients’ behaviors and needs. That is, effective therapists may be flexible in how adherent they are to the techniques of a therapeutic orientation. Therapists who are flexible in their adherence to a therapeutic technique may promote a better therapeutic alliance (i.e., a therapist’s and client’s collaborative agreement on the goals of therapy and what to do in therapy). In this study, Katz and colleagues examined whether the flexible use of some CB techniques by psychodynamic therapists was related to better client outcomes in terms of depressive symptoms. Forty six patients diagnosed with depression were treated by 26 advanced graduate student therapists who were trained to practice psychodynamic therapy. Psychodynamic therapy techniques included: a focus on affect and affect expression, identifying relational patterns and patterns of thoughts and feelings, emphasizing past experiences and interpersonal relationships, working on the therapeutic alliance, and restructuring defense mechanisms. The researchers video recorded two early sessions of therapy which were independently rated to assess the degree to which therapists adhered to psychodynamic therapy principles or to CB therapy principles. Client depression outcomes were assessed pre- and post-therapy. Higher ratings of psychodynamic therapy adherence were related to better patient depression outcomes at post-treatment. In addition, the clients of psychodynamic therapists who used some CB techniques early in therapy had the best outcomes. In other words, the use of psychodynamic techniques was sufficient for clients to improve, but flexible use of some CB techniques by psychodynamic therapists provided added benefit. The CB techniques that were most often integrated by the therapists included: actively initiating topics and therapeutic activities, explaining the rationale of an intervention, focusing on the future, and providing psychoeducation about symptoms.

Practice Implications

Clients in this study improved on average from psychodynamic therapy, and psychodynamic interventions were related to better outcomes. However, clients of therapists who flexibly integrated a small amount of CB techniques benefitted more from the psychodynamic techniques. Research is increasingly showing that therapist flexibility in treatment adherence is related to better patient outcomes. For psychodynamic therapists, flexibility in treatment adherence leads to clients being more responsive to the interventions and having better outcomes.

Fonagy, P., Lemma, A., Target, M., O'Keeffe, S., Constantinou, M., Ventura Wurman, T., . . . Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine, 1-10. Online first publication. doi:10.1017/S0033291719000928

Most psychotherapies are equally effective when it comes to treating depression. However, no single therapy is uniformly effective, so that about 50% of patients might improve when it comes to symptom reduction. So, although there is a large evidence base for treatments like CBT, therapists and patients need access to a range of available treatments. There is less research on psychodynamic therapies, although a number of trials and meta-analyses indicate their effectiveness to treat depression. In the United Kingdom (UK), the health system may offer a stepped care program that provides patients with low intensity guided self-help based on a CBT model followed by more intensive treatment with CBT or IPT if patients did not benefit from self-help. The UK health system rarely offers Dynamic Interpersonal Therapy (DIT), and DIT has never been studied in a randomized controlled trial within the UK health system. Fonagy and colleagues designed this randomized controlled trial to test the efficacy of DIT when compared to the CBT-oriented self-help program as offered in the UK. The study also included a smaller randomized sample of those who received the intensive version of CBT for depression. In total, 147 participants with moderate to severe depression were randomly assigned to DIT, CBT guided self-help, or the intensive version of CBT. The DIT is informed by attachment theory and by mentalization theory, and it views depressive symptoms as responses to interpersonal difficulties or perceived attachment threats. The results of the trial showed a significantly greater effect of DIT compared to guided self-help with regard to depressive symptoms, overall symptom severity, social functioning, and quality of life at post-treatment. The patients receiving DIT maintained these gains up to 1-year post-treatment. Over half of DIT patients showed clinically significant improvements, but only 9% who received the CBT-based guided self-help achieved such improvement. There were no significant differences on any of the outcomes between DIT and the more intensive version of CBT.

Practice Implications

One of the benefits of DIT, according to the authors, is that it offers a treatment manual and curriculum that enables those without a lot of background in psychodynamic therapies to deliver it. This makes DIT potentially widely-applicable in publicly funded health systems like in the UK, Canada, and others. DIT may offer yet another effective option of psychotherapy to therapists and their patients who experience depressive symptoms. The study also points to the limits of offering only guided self-help to those with moderate to severe depression.

Author email: p.fonagy@ucl.ac.uk

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

Grenon, R., Carlucci, S., Brugnera, A., Schwartze, D., … Tasca, G. A. (2018). Psychotherapy for eating disorders: A meta-analysis of direct comparisons, Psychotherapy Research, DOI: 10.1080/10503307.2018.1489162

Eating disorders can cause a great deal of physical and mental impairment because of the severity of the symptoms and because of comorbid conditions like depression, anxiety, substance use, and others. Anorexia nervosa (AN) occurs in about 0.5% of the population, bulimia nervosa (BN) occurs in about 1.5% of the population, and binge-eating disorder (BED) occurs in about 3.5% of the population. Treatment guidelines include both cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as front line interventions for BN and BED. However, results from previous meta analyses of psychological treatments for eating disorders were confounded by not focusing exclusively on randomized controlled trials, mixing studies of adult and adolescent samples, combining an array of outcomes rather than separately reporting primary (eating disorder symptoms) and secondary (interpersonal problems, depression) outcomes, and not distinguishing between bona fide psychotherapies (like CBT, IPT, psychodynamic therapy, and others) from non-bona fide treatments (like self help, behavioral weight loss supportive counseling). Grenon and colleagues conducted a meta analysis of psychotherapies for eating disorders to examine if: psychotherapy is effective compared to a wait list, if bona fide psychotherapy and non-bona fide treatment differ in outcomes, and if one type of psychotherapy (i.e., CBT) was more effective than other bona fide psychotherapies (like IPT, behavior therapy, psychodynamic therapy, dialectical behavior therapy). Their meta analysis included 35 randomized controlled trials of direct comparisons. Psychotherapy was significantly more effective than a wait-list control at post treatment, so that 53.89% of patients were abstinent of symptoms after psychotherapy compared to only 8.92% who were abstinent in the wait-list group. Bona fide psychotherapies (51% abstinent) were significantly more effective than non-bona fide treatments (40% abstinent) at post treatment, and dropout in bona fide psychotherapies (17.5%) was significantly lower than in non-bona fide treatment (29.1%). Further, the difference between CBT and other bona fide psychotherapies was not significant.

Practice Implications

Psychotherapy for eating disorders are effective for patients with BN or BED. There were too few studies of those with AN to come to any conclusions about their treatment. Patients with BN or BED are best treated with a bona fide psychotherapy that involves face to face psychological therapy like CBT, IPT, psychodynamic therapy, dialectical behavior therapy, or behavior therapy. Non-bona fide treatments like self help, behavioral weight loss, and supportive counseling should only be used as an adjunct to bona fide psychotherapy for eating disorders.

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry (AJP In Advance)

Mental disorders are an important health concern that confer high levels of personal and economic burden. Up to 45% of primary care patients have at least one mental disorder. Many practice guidelines indicate that cognitive behavioral therapy (CBT), interpersonal therapy (IPT) , and specific pharmacotherapy interventions as empirically supported for common mental disorders. However, many psychotherapists practice psychodynamic therapy (PDT), and a number of reviews have provided evidence for the efficacy of short-term PDT compared to wait-lists, treatment as usual, and other forms of psychotherapy for depression and anxiety disorders. However, there also have been inconsistent findings with regard to the efficacy of PDT. A particularly strict test of efficacy of a therapy involves a comparison of the treatment to a rival intervention that has established efficacy. Such comparisons in which no differences are expected are referred to as equivalence trials. The problem is that no single study in psychotherapy so far is large enough to test for equivalence (technically, this refers to studies being statistically underpowered to detect a small effect), but a meta-analysis that combines samples from many studies can represent a large enough sample and be adequately powered. In this study, Steinert and colleagues conducted a meta-analysis of randomized controlled trials in which PDT was compared to a treatment established in efficacy. Outcomes included target symptoms (anxiety, depression, etc.) measured with reliable instruments. The authors found 21 randomized controlled trials with 2,751 patients, and all of the comparisons included CBT. Based on predetermined accepted standards, the authors decided that an effect size of g = -0.25 to +0.25 would indicate equivalence (i.e., a small and clinically not meaningful difference). Post-treatment differences between PDT and comparison treatments was g = -0.153 (90%CI: -0.227 to -0.079), and similar results were found at follow-up. In other words there were small, non-significant, and clinically not meaningful differences between PDT and other established treatments with accepted efficacy. The studies were rated as high in quality, there was no effect of diagnosis on the results, and there was no evidence of publication bias.

Practice Implications

This meta-analysis found PDT to be as efficacious as other treatments with established efficacy (i.e., CBT). The finding suggest that established practice guidelines may need to be revisited to include PDT. Response rates for anxiety disorders and depressive disorders (around 50%) for those receiving CBT, and even lower remission rates, indicate that there is room for improvement. Having other treatment options may be particularly important for patients who do not respond to one form of therapy and who may need to be switched to another type of intervention.