The number of psychiatric residents interested in psychodynamic therapies is decreasing. Some are still very interested but this kind of psychotherapy is hardly educated anymore and therapists, supervisors are scarce.
The educational center should have at least one psychoanalyst who is able to demonstrate valid psychodynamic research data in order to satisfy the scientific curiosity of psychiatric residents.
Rigid, stereotyped, psychoanalytic behavior outside of the psychoanalytic treatment situation is not helpful in an educational context. We are not psychoanalysts all the time in our lives, and students do not want to be treated as psychoanalytic patients in an educational setting.
During the residency training, avoid overly abstract psychoanalytical theoretical explanations and remain connected to the clinical situation. Match the teaching of complex psychoanalytic concepts to the level of the residents’ understanding.
Damsa, C., Bryois, C., Morelli, D., Cailhol, L., Adam, E., Coman, A., Stamatoiu, D., Lazignac, C., & Freymann, J. (2010). Are Psychiatric Residents Still Interested in Psychoanalysis? A Brief Report The American Journal of Psychoanalysis, 70 (4), 386-391 DOI: 10.1057/ajp.2010.30
Long term psychodynamic psychotherapy (LTPP) is an effective treatment for complex mental disorders. Long term meaning at least one year or 50 sessions. Complex mental disorders means personality disorders, chronic mental disorders (defined as lasting at least a year), multiple mental disorders (2 or more mental disorders), or complex depression and anxiety disorders.
In all, 11 Randomized Controlled Trials and 12 observational studies were included in this meta-analysis. The 23 studies included 1053 patients treated with LTPP.
The mean (SD) number of sessions carried out in the 23 studies of LTPP was
151.38 (154.98) and a median of 73.50. The duration of therapy was 94.81 (58.79) weeks and a median of 69.00. For LTPP the mean (SD) length of follow-up period after treatment was 93.23 (64.93) weeks.
The authors used a definition of psychodynamic psychotherapy from Gunderson and Gabbard: “A therapy that involves careful attention to the therapist-patient interaction, with carefully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the
therapist’s contribution to the two-person field.”
Transference is defined as, “those perceptions of, and responses to, a person in the here and now that more appropriately reflect past feelings about,or responses to, important people earlier in one’s life, especially parents and siblings.” You can detect transference in everyday life by a strong reaction to a person or situation in which the intensity of the emotion is more than what would be attributable to the current situation may be a clue to the presence of transference.
Resistance is the “patient’s attempt to protect herself or himself by avoiding the anticipated emotional discomfort that accompanies the emergence of conflictual; dangerous; or painful experiences, feelings, thoughts, memories, needs, and desires.”
The authors of this meta-analysis tried to find evidence for publication bias, negative results not being submitted or published. They couldn’t find any, doing such intensive time and work consuming research will probably always be published one way or another.
Observational or randomized controlled trials did not significantly differ in outcome. LTPP was significantly more effective than the shorter-term methods of psychotherapy such as cognitive behavioral therapy. Some cost-effectiveness studies suggest that LTPP may be a cost efficient treatment.
With regard to overall effectiveness, a between-group effect size of 1.8 (95% confidence interval [CI], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups. Further research should address the outcome of LTPP in specific mental disorders and should include cost-effectiveness analyses.
We are talking about patients with severe and debilitating mental illness. This research included a mean follow-up duration of 93 weeks. This is in accordance with a previous post on this blog: Long-term psychodynamic psychotherapy better than short-term
Long-term psychodynamic psychotherapy is superior in the long term to short-term psychodynamic psychotherapy. Short-term produces benefits more quickly than long-term therapies. After 3 years of follow-up, however, the situation was reversed with a stronger treatment effect in the long-term psychodynamic treatment group both for patients with depressive and anxiety symptoms.
To my opinion is LTPP an effective treatment especially for complex psychiatric disorders such as personality disorders. It is ironic that fewer psychiatrists perform these kind of treatments, not only in the US but also in the Netherlands since more evidence is accumulating of it’s efficacy in severe mental disorders. Complex mental disorders and it’s treatment should be the focus of psychiatrist.
F. Leichsenring, S. Rabung (2008). Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis JAMA: The Journal of the American Medical Association, 300 (13), 1551-1565 DOI: 10.1001/jama.300.13.1551
Long-term psychodynamic psychotherapy is superior in the long term to short-term psychodynamic psychotherapy. Short-term produces benefits more quickly than long-term therapies. After 3 years of follow-up, however, the situation was reversed with a stronger treatment effect in the long-term psychodynamic treatment group both for patients with depressive and anxiety symptoms.
If a patient is capable and will benefit from psychodynamic psychotherapy which should be assessed by professionals before hand, than this kind of treatment to my opinion can be of great help to them not only for their complaints but also on the longer term.
Long-term Psychodynamic psychotherapy was out of fashion lately due to the development of other forms of psychotherapy such as cognitive behavioral psychotherapy. These forms of psychotherapy have advantages. They are easier to educate, of short duration and efficacious and cheaper. Moreover, efficacy of long-term psychodynamic psychotherapy was hardly studied in randomized controlled trials. Evidence for it’s efficacy was non existent.
Short-term psychodynamic psychotherapy has been found to be equally effective as other short-term individual treatments, such as cognitive, interpersonal, supportive therapy and solution-focused therapy. The effects of short-term psychodynamic psychotherapy have also been shown to be stable or even to increase during follow-up.
Besides the lack of decent research to the efficacy of long-term dynamic psychotherapy no research was done to the stability of the treatment effects of short-term dynamic psychotherapy. Moreover, long follow-up after treatment with psychotherapy is very rare.
The recent publication of a randomized controlled trial is very welcome.
In the Helsinki Psychotherapy Study, 326 out-patients with mood (84.7%) or anxiety disorder (43.6%) were randomly assigned to three treatment groups (long-term psychodynamic psychotherapy, short-term psychodynamic psychotherapy, and solution-focused therapy) and were followed up for 3 years from start of treatment.
What is solution focused psychotherapy? Solution-focused therapy, which is a brief goal-focused treatment developed from therapies applying a problem-solving approach and systemic family therapy.
What is short-term psychodynamic psychotherapy? Short-term psychodynamic psychotherapy is a brief, focal, transference-based therapeutic approach which helps patients by exploring and working through specific intra-psychic and interpersonal conflicts. Short-term psychodynamic psychotherapy is characterized by the exploration of a focus, which can be identified by both the therapist and the patient. This consists of material from current and past interpersonal and intra-psychic conflicts and the application of confrontation, clarification and interpretation in a process in which the therapist is active in creating the alliance and ensuring the time-limited focus.
What is long-term psychodynamic psychotherapy? Long-term psychodynamic psychotherapy is an open-ended, intensive, transference-based therapeutic approach which helps patients by exploring and working through a broad area of intra-psychic and interpersonal conflicts.Confrontation, clarification and interpretation are major elements, as well as the therapist’s actions in ensuring the alliance and working through in the therapeutic relationship to attain conflict resolution and greater self-awareness. Therapy includes both expressive and supportive elements, the use of which depends on patient needs.
The main differences between short and long-term are the focus in short-term versus the “broad area” in long-term, the importance of the transference and conflict resolution and self awareness in the long-term therapy.
Results
Short-term psychodynamic psychotherapy was more effective in reducing symptoms of depression than long-term psychodynamic psychotherapy at the 7–12 months follow-up, after 3 years of follow-up, long-term psychodynamic psychotherapy was statistically significantly more effective than short-term psychodynamic psychotherapy
During the following 2 years, the symptoms persisted at the level reached in the two brief therapy groups, whereas in the long-term psychodynamic psychotherapy group the improvement continued during the entire 3-year period.
These results are in accordance with the fact that long-term psychodynamic therapists working long term focus on working more slowly and deeply, aiming to produce more global changes by affecting the patient’s longterm vulnerability to stressors.
For solution focused therapy the same conclusions are applicable. It didn’t differ in outcome from short-term psychotherapy.
Now all that is needed is enough psychotherapists capable of doing this form of psychotherapy but most important insurance companies financing these forms of psychotherapy. If you health or life insurance company decides to not full-finance treatments you should look for a viatical settlement provider in order to be able to pay for thems.
Is there a problem or not in your country concerning the availability of long-term psychodynamic psychotherapy, please let me know in the comments.
Knekt, P., Lindfors, O., Härkänen, T., Välikoski, M., Virtala, E., Laaksonen, M., Marttunen, M., Kaipainen, M., Renlund, C. (2008). Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychological Medicine, 38(05) DOI: 10.1017/S003329170700164X
Supportive therapy in psychiatry is mostly done by unexperienced psychiatric residents during their training. Most residents as well as psychiatrists think that supportive therapy is just providing a sense of safety, support self esteem and hope, alternated by advice how patients should live their life, structure their day, get to work and behave. Psychiatrist the least qualified usually apply for the supervision of residents doing these therapies based on these premises.
To my opinion these kind of therapies are the hardest to do, need the most experienced and psychotherapeutic best qualified psychiatrists. Yes psychiatrists because this kind of therapy is mostly done with the most vulnerable patients with sever psychopathology and usually with several diagnoses. Sure residents can be trained in supportive therapy and they should be.
What makes supportive psychotherapy besides the patients in need for it so difficult?
It is not just common sense, interpersonal skills, and a capacity for empathy.To my opinion it is a psychotherapy as dimension of dynamic psychotherapy, to a greater or lesser extent depending on the particular context, problems, and needs of the person. Interpretive approaches and transference work must also be used with the so-called less suitable patients who have a history of immature object relations in this kind of treatment. But it has to be used wisely.
Supportive psychotherapy relies heavily on psychoanalysis in describing characteristic techniques, such as “improving ego functions,” “minimizing the focus on transferential material,” and “confronting maladaptive defenses,” thus assuming some familiarity with ego-psychological psychodynamic theory. For beginning psychotherapists it can hardly be expected to understand what it means to “manage” or “manipulate” the transference in supportive therapy and how this differs from “interpreting” the transference in a more exploratory treatment, let alone which patients under what circumstances require such “management” and why.
Without a good working hypotheses about the unconscious motives, feelings, and conflicts underlying a person’s distress, it is also difficult to see how they would have any basis for predicting what would be supportive or nonsupportive for the individual patient at any given moment in the treatment.
You also need to understand the differences between thinking psychoanalytically in providing support and acting like a psychoanalyst.One of the most important rules is: “Do not say everything you know, only what will be helpful.”
The supportive therapist helps the patient see things more clearly by supporting reality testing, tactfully challenging unrealistic ideas, and demonstrating more effective, less costly ways of defending while supporting adaptive defenses.you have to understand these different aspects in your patient before you can even work on it.
The main priority in supportive psychotherapy is to build a “holding environment” and to foster the therapeutic alliance. This is hard to dose, most unexperienced therapist remain to silent, distant.
It is hard to know about how responsive and self-revealing you should be, about what, and why. The best way to learn this is in supervision. Supervisors should feel free to share their own learning process, including any gaffes, confusion, and embarrassing moments they may have experienced along the way.
You should realize that small improvements can lead to bigger changes and that setting overly ambitious goals will only increase the likelihood of failure. Doing “just enough” is good enough—just enough to reduce anxiety,build self-esteem, instill hope, support deficient psychological functions, and improve overall functioning.
The biggest problem with this effective and satisfying kind of treatment is the lack of a clear definition, consensus about training and guidelines for supportive therapy.
This post is based on Teaching Supportive Psychotherapy to Psychiatric Residents by Carolyn J. Douglas, M.D. and published in the American Journal of Psychiatry 165:4, April 2008, but holds the views of the author of this post: Dr Shock By the way it is an excellent account of supportive therapy
Give Your Mind A Workout on Finding Optimism This is an article on one of my favorite blogs. It is a review of a website. This site offers selfhelp with depression based on Cognitive Behavioral Therapy. This review descibes how this website works as well as the pros and cons. Article in British Medical Journal about psychotherapy on the internet. The reviewed website: http://www.moodgym.anu.edu.au/
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