http://orcid.org/0000-0003-1743-0042
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ABSTRACT
Worldwide, the pressure on psychoanalysis to prove the results of its treatments according to the criteria of so-called evidence-based medicine has increased. While a large number of studies on the results of psychoanalytic short-term therapies are now available, such studies are still largely lacking on psychoanalysis and psychoanalytic long-term therapies. In a large multicentre study, the results of psychoanalytical and cognitive-behavioural longterm therapies in chronically depressed patients were compared, Both psychotherapies led to statistically highly significant changes in depressive symptoms three years after the start of the treatments However, the focus of psychoanalytic treatments is not exclusively on reducing psychopathological symptoms, but on changes in the inner world of the patients that are reminiscent of the goal of psychoanalyses that Freud has characterized as developing “the ability to love, work and enjoy life.” In the German-speaking community, such transformations are called “structural changes.” This article reports results on such structural changes achieved with the help of a sophisticated measuring instrument, the Operationalized Psychodynamic Diagnostics (OPD). These so-called structural changes are compared with symptomatic changes. Three years after the start of the treatments, significantly more patients in psychoanalytical treatments show such structural changes than patients in cognitive-behavioural treatments.
Acknowledgements
We thank all patients who participated, the study therapists and research assistants, interns, students and members of the administrative teams of the participating institutions. We are very grateful to the interviewers, evaluators and trainers of the OPD: Valentina Albertini, Ulrich Bahrke, Katharina Bakker, Heinrich Deserno, Ingeborg Göbel-Ahnert, Amelie Klambeck, Rosalba Maccarone-Erhardt, Alexa Negele, Nicole Pfenning-Meerkötter, Angelika Ramshorn-Privitera, Sabine Stehle, Christa Sturmfels und Heike Westenberger-Breuer. They have been trained by Claudia Oberbracht and Henning Schauenburg.
ORCID
Manfred Beutel http://orcid.org/0000-0003-1743-0042
Notes
* For the partner paper to this paper please see: Leuzinger-Bohleber et al. 2018. ‘Outcome of Psychoanalytic and Cognitive-Behavioural Long-Term Therapy with Chronically Depressed Patients: A Controlled Trial with Preferential and Randomized Allocation’, in The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 1–12.
1 Both treatments had to be clearly defined (see Beutel et al. Citation2012):
Psychoanalytic therapy (PAT) for depression is well described. To insure homogeneity, all study PAT-therapists had to participate in training workshops held by David Taylor from Tavistock Clinic, London and they had access to his recently published and empirically validated PAT-manual specific to treatment of chronic depression. Topics of PAT for chronic depression are: Uncovering and modifying the unconscious determining factors. Idiosyncratic fantasies and conflicts due to developmental deficits and traumatizations are worked through in the “here and now” of the therapeutic relationship aiming at change of psychic structure (“structural change”) Participating psychoanalysts (N = 73) were state licensed and had at least three years of clinical practice.
Cognitive Behavior Therapy (CBT) for depression is based on the work of Beck Lewinsohn as adapted and integrated in a nationally widely used and well accepted treatment protocol (see Hautzinger Citation2013). In general, CBT therapists used five modules (Problem analysis, goals, psychoeducation, rationale for treatment; behavioral activation, increasing pleasant activities; cognitive interventions to re-structure basic assumptions, schemata; social skill training, problem-solving, stress management; maintenance, relapse prevention). State licensed CBT-therapists (N = 44) participated in training workshops held by Martin Hautzinger (cf. Leuzinger-Bohleber et al. Citation2018).
2 The assumption is that structural change will be more durable than symptomatic improvement, e.g. by internalizing the function of the psychoanalyst to help to understand meanings of unconscious fantasies and conflicts. These internalization processes lead to a sustained capability of self-analysis. Structural change thus is a mental capability that is stable over time rather than a transient mental state (see e.g. the discussion in academic psychology concerning “traits” in contrast to “mental states,” e.g. Clark et al. Citation2003).
3 Members of the Executive Committee and authors are Manfred Cierpka, Reiner W. Dahlbender, Harald J. Freyberger, Tilman Grande, Gereon Heuft, Paul L. Janssen, Franz Resch, Gerd Rudolf, Henning Schauenburg, Wolfgang Schneider, Gerhard Schüssler, Michael Schulte-Markwort, Michael Stasch and Matthias von der Tann.
4 We decided to publish the first outcome article three years after the start of treatment for various reasons. The research group of the LAC study had been working already for 15 years. Therefore, it was absolutely necessary to have the main outcome results published. This makes it possible for the younger members of the research group to publish further results, e.g. in the frame of their doctoral theses etc. This means that some psychoanalytic treatments are still ongoing and that not all patients have been investigated five years after the beginning of treatment.
5 In the Consort diagram of the first outcome article (Leuzinger-Bohleber et al. Citation2018), we showed in detail which reasons led to the exclusion of some of the 554 patients interviewed. N= 55 had not met the inclusion criteria, N = 70 had not reached the required severity of symptoms, N = 8 had to be included in inpatient treatment, N = 63 revoked their consent to participate in the study, N = 11 chose a non-study therapist, N = 13 dropped out due to difficulties regarding timely referral, N = 16 switched to another therapy arm, N = 14 deviated from the treatment protocol, N = 7 were incorrectly included in the study and therefore had to be excluded subsequently, N = 45 had further reasons that they could not be included in the study.
6 The homogeneity of the sample was tested by the methodological centre (see Leuzinger-Bohleber Citation2018).
7 The effect sizes were very high (BDI: d = 1.17 after one year; 1.83 after three years; QIDS-C: d = 1.56 after one year; 2.08 after three years) (according to Cohen [1988], d = .04: small effect size; d = 0.7: medium effect size; d = 1.0: high effect size) (Leuzinger-Bohleber et al. Citation2018).
8 We tried to keep the number of sessions comparable during the first year. Afterwards, the treatments should continue according to the needs of the patients and the conceptualization of the treatments by the therapists (e.g. CBT followed the guidelines of a so-called “relapse prevention therapy”). According to the study protocol, PAT should not offer more than 80 sessions, CBT no fewer than 60 sessions during the first year of treatment. Our data showed that the therapists followed their naturalistic practices more than the study protocol: PAT had a mean of 80.4 sessions (SD 27.8) during the first year of treatment, CBT had a mean of only 32.5 (SD 9.0) therapy sessions.
9 For understanding “structural changes,” it is important to consider these criteria. Moving from stage 3 to stage 4 on the HCSC means e.g. a categorical change: the different stages have a specific meaning that is evaluated by the raters. In contrast to other scales, there is not simply a continuity in intensity: it is a fundamental difference in quality of the level of psychic functioning. Twenty-eight (15 CBT, 13 PAT) patients whose criteria for “structural change” are only partially fulfilled (less than two foci of 4 or a change score smaller than 1.5 stages) are not taken into account in the analyses of positive vs. no structural change, as described below.
10 “Time and cost considerations aside, the technique of meeting three, four or five times per week for several years creates a special opportunity to activate old memories and observe their influence on present-day construals and emotional experiences with an emotional intensity and vividness that is difficult or impossible with other methods (Freud 1914/1958). As such, this approach has the potential to offer something not available with other modalities that can have pervasive effects on a person’s functioning in a wide variety of social, occupational, and avocational settings. New learning can involve improvement in function above and beyond symptom reduction, such as better self-esteem, greater ability to tolerate and manage stress, improved flexibility in social relations, a greater capacity for intimacy and the construction of a coherent life narrative that exceed what would be expected based on symptomatic improvement alone (Shedler 2010)” (Lane et al. Citation2015, 16).
11 Another reason for choosing Ms B. was that we have already summarized the beginning of her psychoanalysis in a former German publication which juxtaposed the initial phases of a behavioural therapy with a psychoanalytic treatment in the LAC study (Leuzinger-Bohleber et al. Citation2010). There was a discussion of similarities, as well as of important differences regarding therapeutic approach, aims and treatment technique, while, at the same time, an explanation was given as to what extent the psychoanalytic treatment was referencing the manual for the treatment of chronically depressed patients by David Taylor (Citation2010), which had been used as a basis in the LAC study. Due to the scope of this article, we limit ourselves to the psychoanalytic treatment.
12 Following the Three-Level Model for Clinical Observation, psychoanalytical sessions from the beginning, the middle and the end of psychoanalysis had been presented and intensively discussed with the clinical team of psychoanalysts in Frankfurt. The following summary of the psychoanalysis was “expert-validated,” which means: (a) the summary of the psychoanalysis followed a systematic compression of the clinical material (as described in the Three-Level Model); and (b) members of the clinical teams had read and commented on several drafts of the case study. Their comments have been considered in the case study (see e.g. Leuzinger-Bohleber 2014).
13 It was a “psychoanalysis on the couch”—first with four sessions, in later phases of psychoanalysis with three, and in the fifth year with two sessions a week.
14 As was discussed in Leuzinger-Bohleber et al. (Citation2018), due to ethical reasons medication could not be withheld in this group of severely ill patients. Only baseline medication was taken into account in our analyses, but the influence of medications on therapy outcome was not in the focus of our design. Instead we have documented the use of medication in our trial and will publish our findings in separate publications. But it is more a naturalistic kind of study investigating the practice of medication in our LAC sample. We had no funding or the resources to do a combined medication-psychotherapy trial.
15 “One must conclude that there is something about the combination of arousing emotion and processing that emotion in some way that contributed to therapeutic change, but the specifics of what it is about emotion that actually brings about change are not clear” (Lane et al. Citation2015, 2).