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Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W. et al. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, Advance online publication: doi:10.1176/appi.ajp.2014.13111514.

Social anxiety disorder is a highly prevalent mental disorder, with lifetime prevalence of about 12% in the population. As Leichsenring and colleagues note, the disorder has an early onset and can have a chronic course leading to many psychosocial impairments. Also, social anxiety disorder often is comorbid with depression. There is good evidence for the efficacy of cognitive behavioral therapy (CBT) for social anxiety disorder and some evidence for psychodynamic therapy (PDT), but most studies have only assessed short term outcomes. In this large mulit-center randomized controlled trial comparing CBT and PDT for social phobia, Leichsenring and colleagues report on outcomes up to 2 years post treatment. The study had 416 adult patients randomly assigned to one of the treatments, and 79 randomly assigned to a waiting list. Outcomes were reported at post, 6 months, 12 months, and 24 months post treatment, and included remission of social phobia, depression levels, and interpersonal problem scores. The CBT intervention for social phobia was based on the model by Clark and Wells. The PDT was based on Luborsky’s model but specifically adapted for social phobia. Participants received 25 sessions of individual therapy, and therapists received advanced training in the models. CBT resulted in significantly greater remission of social phobia than PDT at post treatment, but the difference was small. Remission rates at 6, 12, and 24 months post treatment were not different between treatments. At 2 years post treatment 39% of those receiving CBT and 38% of those receiving PDT no longer had clinical symptoms of social phobia.  Results were similar for interpersonal problems in which CBT showed an earlier response, but the two treatments were equivalent at each follow up. Depression scores improved for both interventions at post and follow ups.

Practice Implications

The findings of this large study suggest that both CBT and PDT are effective treatments for social phobia. Although CBT had a small advantage at post treatment, PDT appeared to have an “incubation effect” in which patients continued to work on interpersonal problems and symptoms of social phobia over the longer term. Despite these positive outcomes, Leichsenring and colleagues suggest that there remains room for improvement in treating social phobia. Those who do not respond to these interventions may require different forms of treatment that is more specific, intense, or of longer duration. Leichsenring and colleagues also suggest integrating elements of the effective treatments within a single protocol. Although intuitively appealing, this integrated approach has not been tested.

Barber, J.P., Muran, J.C., McCarthy, K.S., & Keefe, J.R. (2013). Research on dynamic therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 443-494). New York: Wiley.

In this part of their chapter, Barber and colleagues (2013) summarize the research on the efficacy of dynamic therapies for personality disorders. As the authors indicate, dynamic therapies refer to a family of interventions that: focus on the unconscious, affect, cognitions and interpersonal relationships; use interpretations and clarifications; consider transference and countertransference; and use the therapeutic relationship to improve self understanding and self-awareness. Following Magnavity (1997), the authors describe dynamic therapies specifically for personality disorders as identifying maladaptive, recurring patterns of thinking, behaving and emotional responding with the intent of restructuring these through linking current and transference patterns to early attachment and trauma. Barber and colleagues conducted meta analyses of available research on dynamic therapies for personality disorders. They combined several outcomes based on patient and observer reports as an index of general outcome. In seven studies representing 452 patients, dynamic therapies for personality disorders were more effective than control conditions (i.e., treatment as usual, or wait-lists), and the size of the effect was moderate. They found no significant differences between dynamic therapies and other types of therapy for personality disorders. Dynamic therapies had significant advantages over control conditions for general symptomatology, interpersonal problems, personality pathology, and suicidality. These therapeutic effects were maintained to short-term follow up.

Practice Implications

There are now several dynamic therapies for personality disorders that have substantial research evidence for their efficacy. For example, Transference Focused Psychotherapy for borderline personality disorder is considered a “well-established” treatment by the American Psychological Association Division 12. Mentalization-based treatment is also considered to be “probably efficacious”. Other “probably efficacious” dynamic therapies include: McCullough-Vaillant’s short term dynamic psychotherapy (STDP) and brief relational therapy for Cluster C personality disorders (i.e., avoidant, dependent, obsessive-compulsive); and intensive STDP for general personality disorder.

Ferrari, A.J., Charlson, F.J., Norman, R.E., Patten, S.B., Freedman, G., et al. (2013). Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Medicine, 10(11): e1001547. doi:10.1371/journal.pmed.1001547.

Depressive disorders are among the most common mental disorders that previously were described as a leading cause of burden in the world.  In epidemiological literature, burden is defined in several ways. One common metric is “disability adjusted life years” (DALYs) which represents loss of a healthy year of life. DALYs can be aggregated into the “years of life lived with disability” (YLD). Another metric is the “years of life lost due to premature mortality” (YLL). Each of these metrics of burden can be estimated from aggregating data from a number of studies and meta analyses that assess burden world wide. Such epidemiologic studies can also look at relative burden across countries, ages, and sex. In the 2000 Global Burden of Disease report, depressive disorders were the third leading cause of burden after lower respiratory infections and diarrhoeal diseases. Depression was also the leading cause of disability, responsible for 13.4% of years of life living with disability in women and 8.3% in men. In this study by Ferrari and colleagues, the authors provide a 2010 update to the Global Burden of Disease report for major depressive disorder and dysthymia. Major depressive episode is the experience of depressed mood almost all day, every day, for at least 2 weeks. Dysthymia involves a less severely depressed mood with duration of at least 2 years, a chronic rather than episodic course, but with low rates of remission. Ferrari and colleagues reviewed over 700 studies from 1980 to 2010. Prevalence (i.e., current rate) of major depression and dysthymia in the world population is 5.95%, representing nearly 400 million people. Major depression (4.4%) occurs more frequently than dysthymia (1.55%). Major depression occurs more frequently among women (5.5%) than men (3.2%). Major depression accounted for 8.2% of all years lost to disability, making it the second leading cause after low back pain. The percent of years lost due to disability increased since 1990, largely due to population increases and aging of the world population. The highest level of burden due to depression was seen in Afghanistan and the lowest in Japan. In terms of world regions, North Africa and Latin America showed the highest levels of burden due to depression. The authors also reported that 2.9% of disability adjusted life years from ischemic heart disease can be attributed to major depression.

Practice Implication

This study joins others in past decades to define depression as a leading cause of years lost to disability worldwide, with over 400 million people suffering from a depressive disorder. The increasing burden of depression is partly due to decreasing mortality caused by other diseases in developing countries and population aging. Countries that have recently experienced conflict (e.g., Afghanistan, North Africa, Middle East) were particularly burdened by depression. But research has also linked depression to intimate partner violence and child sexual abuse. Mortality is elevated with major depression, as is disability related to other medical problems like heart disease. This epidemiological research points to the importance of identifying and treating depression in the population. Psychotherapeutic interventions provide highly effective treatments for depression.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

This month I consider the section in Crits-Christoph and colleagues’ chapter on the process of psychodynamic therapy (PDT). There are a number of PDT models, but they each share some fundamental aspects of treatment or purported mechanisms. One is insight or self understanding, in which patients learn about themselves and their relationships through interventions like interpretations. Self understanding is expected to help patients reduce symptoms by increasing adaptive responses in their important relationships. Transference interpretations may help patients understand their patterns within the therapy relationship, address or change these patterns, and generalize the changes to relationships outside of therapy. Another mechanism might be changes in defensive functioning. Defense mechanisms may be expressions and means of coping with unconscious conflict, needs, and motivations. Change in defensive functioning from less adaptive (e.g. acting out, passive aggression) to more adaptive (e.g., altruism, self observation) may be necessary to achieve improvement in symptoms. Crits-Christoph and colleagues addressed four questions in their review of research on the process of PDT. (1) Are the uses of PDT techniques like transference interpretations related to treatment outcomes?  A number of studies have associated the use of PDT interventions and outcomes, and the average effect size is moderate. In general, transference interpretations were associated with better treatment outcomes. However the findings for transference interpretations are complicated. For example, the use of too many transference interpretations may not be therapeutic and may result in poorer outcomes. A small number of studies looked at the quality or accuracy of transference interpretations and found a moderate relationship between accurate interpretations and good outcomes. Most of these studies did not control for previous improvement in outcomes, so an alternate explanation might be that patients whose symptoms improve facilitate therapists to provide more effective transference interpretations. (2) Is patient self-understanding or insight associated with positive outcomes in PDT? Crits-Christoph and colleagues concluded from their review that changes in self-understanding is an important part of the therapeutic process of PDT. The relationship between insight and outcomes were not evident in CBT or medication interventions, thus suggesting that self-understanding is a specific mechanism of PDT. (3) Is change in defensive functioning related to outcomes in PDT? Only four studies have looked at this question. The studies suggest that improved defensive functioning is related to good outcomes especially for those with more severe problems. However, it remains unclear whether change in defensive functioning causes change in symptoms or the other way around. (4) Is therapist competence in PDT related to treatment outcomes? There is some evidence that competence and adherence in delivering PDT were related to good patient outcomes. Some research also showed that competence and adherence to PDT protocols preceded or caused good outcomes.

Practice Implications

There is good evidence that transference interpretations are related to outcomes, but therapists need to use these judiciously. The research suggests that too many transference interpretations in those with lower levels of functioning, or inaccurate interpretations in general, can reduce outcomes or be related to poorer outcomes. There is also good evidence that patient self understanding of relationship patterns will result in positive outcomes. Self understanding or insight may be a specific mechanism by which PDT works that sets it apart from CBT and the effects of medications. The research also indicates some evidence for the positive effects of changes in defensive functioning, but it is not clear whether change in defenses is a cause of or caused by positive symptom outcomes. Therapist competence and adherence in delivering PDT is also related to good patient outcomes. This highlights the need for training and supervision in evidence based PDT interventions.

Driessen, E., Van, H.L., Don, F.J., Peen, J., Kool, S. ....Dekker, J.J. (2013). The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: A randomized clinical trial. American Journal of Psychiatry, 170, 1041-1050.

Psychotherapy is one of the most widely used treatments for major depression. Unfortunately there is no commercial entity like the pharmaceutical industry to support research and development of psychotherapy. As a result, researchers have limited ability to conduct larger-scale studies of comparative treatment effectiveness, of which there are only a handful. Although psychodynamic therapy (PDT) has been used to treat depressed patients for decades, randomized controlled trials of its efficacy are relatively infrequent. A concurrent problem with outcome research in psychotherapy is that sample sizes tend to be too small to actually test if two treatments are equivalent in what is called an “equivalency trial”. Without large samples, all one can conclude is that two treatments are “not significantly different” (a statistical note: an equivalency trial is planned from the outset to have a large enough sample to test the hypothesis that, with 95% certainty, the effect of one treatment falls within a narrow, predetermined margin of the effect of another treatment). The study by Driessen and colleagues was conducted in several sites in Amsterdam, in which 341 patients seeking outpatient psychotherapy for depression in psychiatric clinics were randomized to PDT or cognitive behavioural therapy (CBT). This is largest trial ever of PDT. Participants received 16 weeks of therapy and then were followed up for 1 year. About 40% of patients started with severe depression. Therapists were 93 experienced and well trained therapists who provided one of the two treatments. The main outcome was remission from depression, defined by achieving a low score on a validated observer rating scale. Post treatment remission rates were 21% for CBT and 24% for PDT, indicating that the treatments were equivalent.

Practice Implications

Cognitive-behavioral therapy (CBT) and short-term PDT provided similar outcomes for patients with a major depressive episode, but remission rates at the end of treatment were low for both treatments. Lower remission rates were likely due to the greater level of severity for these patients compared to those seen in primary care settings. The results highlight that even the best available psychological (and pharmacological) treatments yield modest outcomes for more severely depressed patients. Nevertheless, this rare equivalency trial found that both CBT and PDT were equivalent in terms of outcomes for these patients.

Author email: e.driessen@vu.nl

Ulvenes, P. G., Berggraf, L., Hoffart, A., Stiles, T. C., Svartberg, M., McCullough, L., & Wampold, B. E. (2012). Different processes for different therapies: Therapist actions, therapeutic bond, and outcome. Psychotherapy, 49(3), 291-302.

One of the few truisms of psychotherapy is that the therapeutic alliance is important to treatment outcomes. But does the alliance work similarly in Cognitive Behavioral Therapy (CBT) and in Psychodynamic Therapy (PDT)? Therapeutic alliance is defined by three elements: the bond between client and therapist, agreement on tasks, and agreement on goals. Compared to PDT therapists, CBT therapists tend to focus more on cognitions and focus less on emotions, and so the bond may be less important in CBT than agreement on tasks and goals. Will the bond between client and therapist be differentially affected by the differing focus on emotions between CBT and PDT? A study by Ulvenes and colleagues (2012) looked at this question. This study is a follow up study of a randomized controlled trial comparing CBT to PDT for the treatment of cluster C personality traits (i.e. individuals who have trouble in experiencing and expressing emotions, and in developing close relationships). Fifty clients were randomized to either CBT or PDT, therapy was short term, and therapists were experienced and competent in delivering their therapy. In the previous study the authors reported that CBT and PDT were both equally effective in treating clients with cluster C personality disorder. In the current study, the authors found that therapist avoidance of affect was associated with developing a greater bond with patients in both CBT and PDT. That is, Cluster C patients liked their therapists better if the therapists avoided talking about the clients’ feelings. However, focusing on affect in PDT was also associated with positive outcome. In other words, therapists who avoided talking about emotions in PDT helped the patient like the therapist better, but this was counterproductive for good outcome. PDT therapists had to manage to create a bond despite their focus on affect in order to achieve good outcomes. On the other hand, focusing on affect in CBT was associated with poorer outcome. That is, therapists who avoided affect in CBT, which is consistent with the treatment model, had clients who experienced both a better bond and better outcomes. Therapeutic alliance is important for all therapies, but may operate quite differently depending on how much the therapy focuses on affect (PDT) or on cognitions (CBT).

Practice Implications

PDT therapists working with cluster C patients have to negotiate a complex task of maintaining a bond despite the treatment model’s focus on emotions in order to achieve good outcomes. CBT therapists will do well to be consistent with the treatment model and focus primarily on cognitions to help with the bond and promote good outcomes. CBT therapists in particular may need to develop a strong bond before agreeing on tasks and goals, which are also keys to a therapeutic alliance.

Author email: pal.ulvenes@modum-bad.no