Brief Psychodynamic. psychotherapies. Past, Present, and Future Challenges

Transcription

1 Brief Psychodynamic Psychotherapies Past, Present, and Future Challenges JERALI) KAY, M.D. The future educational and research needs of briefpsychodynamic psychotherapy are discussed. Specfic shortcomings of current education and training in brief dynamic therapies are elucidated. Many of these are relevant to psychotherapy instruction in graduate medical education in nondynamic treatments as well. Educational and technological recommendations are suggested to remedy these shortcomings. (The Journal of Psychotherapy Practice and Research 1997; 6: ) M anaged care has had a dramatic influence on the recent conceptualization of psychotherapy models and the delivery of brief psychotherapy services. The advent of brief dynamic psychotherapy, however, precedes managed care by decades; indeed, Freud himself relieved Gustav Mahler s impotency through interpretation in a single four-hour meeting. H I S 1 0 H I C A I. I N T R 0 1) U C 1 I () N Although both Rank, through his focus on separation, and Ferenczi, through his highly active therapeutic stance, provide some continuity for many of today s briefer treatments, it was Alexander and French who contributed most significantly to modern brief psychodynamic psychotherapies. Like Rank and Ferenczi, Alexander and French were concerned that psychoanalysis had become highly intellectualized. They favored a more emotional experience for the patient within the therapeutic relationship and introduced the concept of the corrective emotional experience. The corrective emotional experience, considered heretical by traditional analysts up until the recent past, advocated an intentional assumption by the therapist of a From the Department of Psychiatry, Wright State University School of Medicine, Dayton, OH Send correspondence to Dr. Kay at the above address. Copyright 1997 American Psychiatric Press, Inc. VOLUME 6 #{149} NUMBER 4. FALL 1997

2 KAY 331 stance different from that of the patient s original traumatizing or disappointing object. For example, if the patient as a child experienced his mother as intensely invasive, the psychotherapist would adopt a relaxed, nonintrusive attitude toward the patient. Alexander and French were accused of abandoning therapeutic neutrality by manipulating the patient. They in turn argued that the corrective emotional experience permitted the patient to appreciate more clearly the irrationality of his or her feelings. Alexander and French anticipated many of today s values and models of brief psychotherapy. They disagreed with the traditional psychoanalytic notion that most important psychological work occurs within analytic sessions. Most of the work, they argued, should take place outside of sessions, through reflection and through encountering new life experiences. They believed, moreover, that some patients improved more quickly with onceweekly meetings and that five sessions weekly promoted significant regression in some patients and promoted avoidance of real-life experiences critical to enhancing therapeutic gains. Alexander and French relied on planned interruptions in therapy that lasted from 1 to 18 months to assess what issues required further work by the patient. Such interruptions, by promoting independent functioning, evoked greater confidence in the patient. These interruptions also assisted in the decision about termination and promoted the patient s ability to apply more readily that which had been learned in treatment. Planned interruptions are highly compatible with today s managed care values of episodic treatment. The systemization of dynamic brief psychotherapy began in the 1970s with the writings of Malan,2 Mann,3 Sifneos,4 and Davanloo.5 All four of these authors based their brief treatments on the psychoanalytic principles of transference, psychic conifict, and ego mechanisms of defense and on traditional drive theory. Each, however, placed different emphases on the importance of some of these theoretical constructs. For example, Mann s approach is much more comprehensive and less focused on drive theory than are Sifneos s and Davanloo s. Each of these models, as opposed to many of the new brief dynamic treatments, does provide a consistent theoretical position that explains psychopathology and mutative factors. Together, these clinicians formulated some of the enduring features of psychodynamic brief treatments. These include the following characteristics: #{149}Adefinite time limit to the treatment. #{149} Selection of a treatment or problem focus no later than by the second or third session. #{149} Rapid establishment of a therapeutic alliance. #{149} A high level of therapist activity (compared with psychoanalysis). #{149} More frequent use of confrontation and elicitation of anxiety (especially by Sifneos and Davanloo). #{149} Use of interpretation and transference to demonstrate the link between past and present emotional problems. Important new models of dynamic brief therapy, largely based on research, were introduced in the 1980s. These included, but were not limited to, the models of Horowitz, addressing Short-Term Dynamic Treatment of Stress Response Syndromes;6 Luborsky s Short-Term Supportive-Expressive Psychoanalytic Psychotherapy;7 and Strupp and Binder s Time-Limited Dynamic Psychotherapy.8 Moreover, there are a number of other predominantly psychodynamic brief treatments that are either less well known to clinicians or, in some cases, lack the scientific rigor of the previous three treatment approaches. -12 Nearly every major psychoanalytic approach has a brief therapy model. Accelerated Empathic Psychotherapy 3 based on self psychology and brief treatment based on control mastery theory 4 are but two examples. The newest psychodynamic approach to the treatment of panic disorder is that of Milrod et al. 5 Although not yet validated, their approach shows promise as a treatment intervention in JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

3 332 BRIEF PSYCHODYNAMIC PSYCHOTHEHAPIES light of the high relapse rates after discontinuation of medication or cognitive-behavioral therapy of patients with panic disorder. Conspicuous by its absence in this cursory review is Klerman et al. s Interpersonal Therapy (IPT). 6 Although many psychiatrists integrate 1FF with psychodynamic psychotherapy in the treatment of depression and other disorders, this practice has not been studied. Kierman, however, was quite clear that 1FF is not a psychodynamic treatment. 1FF is based on Adolph Meyer s psychobiology theory (which emphasized adaptation to environment and the role of life experience), Harry Stack Sullivan s interpersonal process theory, and John Bowiby s attachment theory, which highlights the psychological dysfunction that accompanies disruption and loss of relationships. RESEARCH S E C E C T E D FINDINGS The brief dynamic psychotherapy approaches currently in use have been comprehensively examined in two excellent overviews. 7 8 Rather than offer in-depth discussion of all of these approaches, I present here selected findings of research into the brief dynamic therapies. Compared with 1FF and cognitive-behavioral therapy, most of the brief psychodynamic psychotherapies have not been supported by rigorous efficacy or effectiveness research. Efficacy is determined through the use of randomized controlled studies. Effectiveness and cost-effectiveness refer to a treatment s success in situations that more closely approximate actual clinical practice. Randomized controlled studies often have limited generalizability to clinical practice because in their pursuit of internal validity they study diagnostically homogeneous patient populations, use therapists who are trained to provide a pure or nonrntegrative treatment based on manuals, and employ monitoring of patient progress as well as therapist adherence. Some efficacy studies lack long-term follow-up, which is central to measuring endurance of treatments gains. By definition, randomized controlled studies also exclude subthreshold cases wherein patients present with psychological problems that cause significant pain or dysfunction but fail to meet DSM criteria for a particular disorder. These subthreshold cases are quite common in private practice. Similarly, the problem of comorbidity, which may be the rule rather than the exception in private practice, is not addressed in most rigorous controlled studies. There has been insufficient research involving psychoanalysis and long-term psychoanalytic psychotherapy. In the brief dynamic therapies as well, sufficient research simply has not been carried out. 9 It is impossible in many instances, therefore, to speak of either the efficacy or the effectiveness of many of these treatments. The dearth of investigations, however, does not substantiate inefficacy or ineffectiveness; there is broad-based empirical and heuristic support for psychoanalytically informed psychotherapy.20 Pertinent research findings on brief psychodynamic psychotherapy can be summarized as follows: #{149} Brief psychodynamic psychotherapy, when compared in two meta-analyses of 19 and 11 studies with other psychotherapies, was superior to no treatment at 1 year However, these meta-analyses examined few studies in common, and the meta-analysis by Crits-Christoph23 used more rigorous inclusion criteria regarding patient selection, therapist experience, and adherence to models. His meta-analysis was able to demonstrate that dynamic brief treatments are as effective as other brief therapies. Unfortunately, Crits- Christoph s study can be criticized because it included 3 trials where patients were treated by therapists using 1FF. #{149} Time-limited psychotherapy appears to be as helpful as, but not more helpful than, unlimited long-term psychodynamic treatment.226 There is a demonstrated dose-response effect in that the more treat- VOLUME 6. NUMBER 4. FALL 1997

4 333 ment patients receive, the more improvement or depth of psychological change they show #{149} There are insufficient data to prove that any one form of brief psychodynamic psychotherapy is more effective than another. #{149} Although patients in brief treatment tend to experience enduring gains,29 30 there is increasing evidence that further psychotherapy is frequently needed, helpful, and quite common in the treatment of some disorders and emotional problems. #{149} Characterological problems tend to require longer periods of treatment than do symftoms such as depression and anxiety. #{149} Outcome measures employed in many brief treatment studies do not adequately reflect the measures traditionally agreed upon to determine the success of longterm psychoanalytic therapy and psychoanalysis.3 In summary, with regard to the efficacy and effectiveness of brief dynamic psychotherapies, absence of evidence is not evidence of absence. i III; FUTURE OF BRIEF scious; pathogenic beliefs; and defense mechanisms.3234 However, dynamic brief therapies will advance only through greater internal validation. Above all, it is important to remember that the absence of comparative studies of brief dynamic treatments and of long-term psychoanalytic psychotherapy accounts for the confusion in the field. Very few initiatives have thoroughly evaluated the efficacy or effectiveness of psychodynamic psychotherapy. In essence, psychodynamic psychotherapy has not been proven ineffective. Key research issues that must be addressed in the very near future for brief and long-term psychodynamic treatments are listed in Table i.3 Educational Challenges: Psychotherapy Instruction In addition to the problem of limited research, the most potent threats to the future psychiatric practice of dynamic psychotherapy reside in the inefficiency and nonstandardized instruction of psychotherapy training, the failure to appreciate the critical skills, attitudes, and knowledge required to conduct psychotherapy, and the confusing psychotherapy pedagogy. I)vNII(; TREATMEN FS The Need for Research TABLE 1. Research challenges for psychoanalytic psychotherapy #{149}Determining efficacy for specific disorders Scientific and economic pressures are resulting in less willingness to embrace heuristic models without outcome measures showing their effectiveness in the treatment of specific conditions. While a psychodynamic approach to clinical interactions continues to be the most comprehensive approach to the understanding of the subjective illness experience, loss, conflict, and other traumatic or intensely disappointing experiences, it is clearly not the best treatment intervention for all clinical situations. Empirical evidence supports some of the basic psychoanalytic concepts on which all brief dynamic therapies are based: the uncon- #{149}Developing treatment guidelines for interpersonal problems and personality disorders #{149}Developing reliable and valid self-report measures for core conificts #{149}Measuring potential cost-offset of different therapies #{149}Determining efficacy of short-term versus long-term psychotherapies #{149}Matching patients to treatment on basis of personality, functional level, or developmental stage #{149}Examining whether and how experienced therapists can be trained in short-term psychoanalytic treatments #{149}Learning the limits of brief therapy and conditions or symptoms for which longer term psychotherapy should be recommended. Note: List derived from Barber l994. JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

5 334 BRIEF PSYCHODYNAMIC PSYCHOTFIERAPIES Psychotherapy educators in psychiatry have disappointed the field in at least seven critical areas: 1. They have not developed and introduced new educational technologies in residency education. 2. They have not integrated psychotherapy research findings and emphasized that effective psychotherapy is predicated on clinical decision making and treatment planning. 3. They have not conducted meaningful research on psychotherapy training. 4. They have not provided integrative models of psychotherapy, especially those integrating medication and psychotherapy. 5. They have not acknowledged that although manual-guided training may succeed in bringing trainees to a criterion level of adherence to technical procedures, there is little evidence that it improves therapy outcomes or that a therapist practices skillfully. In short, adherence is not the same as competency. 6. They have underestimated in some cases the challenges of leaming and conducting effective brief dynamic therapy within the training setting. These challenges include #{149} The difficulty in selecting a therapeutic focus in some clinic patient populations, where significant and complex psychosocial problems are the rule and comorbidity is commonplace. #{149} The ethical concerns and the strong feelings (often anger toward the clinical setting and guilt) aroused in trainees when they are obligated to limit treatment to their patients or to adhere to forced or unplanned terminations. #{149} The impact of learning the limitations of brief interventions with respect to symptom alleviation and characterological change. #{149} The daunting challenge of grasping the importance and role of transferenceand technical concerns about it-within brief therapies. 7. They have also failed in influencing accreditation processes by not demanding more specific educational outcomes and by stipulating pedagogical methods for maximizing training experiences rather than emphasizing locations and durations of rotations. If psychotherapeutic skills are to remain in the core professional identity of psychiatrists, new pedagogical approaches to the teaching of psychotherapy must be developed and implemented. This need has arisen because #{149} There are too many idiosyncratic teaching methods and too little standardization across training programs. #{149} Although most programs make use of clinical experiences, individual supervision, and didactics/conferences, little new has been added to our teaching methods in 50 years. #{149} Faculty, for the most part, remain reluctant to conduct psychotherapy in front of trainees for teaching purposes and their academic departments for peer review. #{149} A minority of faculty still attribute difficulties in trainee-administered psychotherapy wrongly to countertransference issues and not deficits of knowledge or skill. #{149} The demise of the comprehensive psychiatric or case formulation, not the DSM-III and its successors, has been responsible for increasingly superficial assessments of patients. Case formulation must be revitalized to provide residents with a new pragmatic-but partly causal-methodology that will enable them, in the context of their phenomenological or descriptive presentations, to suggest reasons for each patient s crisis, symptom formation, and enduring pathological beliefs. #{149} Many psychoanalysts have long recognized the disjunction between metapsychology and psychoanalytic practice. It is time to jettison metapsychological constructs that are confusing and superfluous to learning the basic science of psychodynamics. VOLUME 6 #{149} NUMBER 4. FALL 1997

6 KAY 335 #{149} Faculty who teach psychotherapy must have a theory of cure to conceptualize for trainees how behavioral or motivational change occurs. Without such a tool, residents become overwhelmed by the specificity-nonspecificity battle and the irrelevant schism. biology-versus-psychology #{149} Although the practice of having residents undergo psychotherapy has recently fallen out of favor, its possible functions in educating and professionalizing residents should be revisited and, if indicated, new models for providing quality and reduced-fee treatment to residents should be developed. Psychotherapy may provide firsthand experience for residents with the patient role, the power of the doctor-patient relationship and transference, the role of the unconscious, the centrality of empathy, and the impact of correctly timed and framed interpretations. #{149} More than any other portion of the residency curriculum, psychotherapy instruction varies from program to program. Master clinicians must assume leadership in establishing a standardized curriculum, not a model curriculum, for psychotherapy education. The development of text material must be accompanied by computer-assisted instructional formats portraying model treatments by master clinicians in addition to decision-making exercises in psychotherapeutic interventions. #{149} Lessening the divergence between psychotherapy research and practice35 is an educational issue. Research findings should be integrated into educational programs; case studies should no longer be disparaged (they can be scientifically rigorous in testing a hypothesis); researchers should include clinical vignettes and details about their techniques when describing their research; research should be undertaken to determine what types of psychotherapy research is helpful to clinicians; and further study is needed of the accessibility and comprehensibility of research findings.36 Educational Challenges: Is There a Need for New Supervisory Models? Most therapists have never been trained in any method of supervision. At least in psychiatry, see one, do one, and supervise one remains the pathway to becoming a supervisor. Although this model remains prevalent in medical education, it is no longer particularly attractive. In many psychotherapy training situations, faculty are unclear how to assist trainees in defining the goal of treatment and in identifying a core conflictual theme, focus, cyclical maladaptive pattern, or central issue. In short, current supervision in many programs is theoretically diffuse and unfocused. New methods that assess the helpfulness of supervision to the trainee and the impact of supervision on the quality of care provided by the trainee are desperately needed. As increasing pressure to generate larger parts of their salaries diverts faculty from teaching, the professional development of the young psychotherapy supervisor is in jeopardy. Although manual-driven treatments have advanced psychotherapy research and patient care, we do not have a manual for supervision or standards that address knowledge, attitudes, and skills necessary for effective supervision.37 Audio-visual (A-V) model cases for supervisors should be developed to promote knowledge, skills, and helpful attitudes about the challenges and techniques of supervising trainees. Similarly, A-V practice tapes that would assist the trainee in recognizing a therapeutic focus or transference are greatly needed. Supervising of supervisor and trainee could be improved through the use of computer-assisted and interactive video technology. Examples of innovative programs can be found at the University of Pennsylvania. Dr. Aaron Beck s program uses phone supervision for trainees conducting cognitive-behavioral JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

7 336 BRIEF PSYCHODYNAMIC PSYCHOTHERAPIES therapy. This apparently has been quite helpful for volunteer faculty, who, after reviewing the trainee s taped therapeutic sessions, can address issues of behavior, style, and adherence to manual treatment. Dr. Lester Luborsky, at the same institution, has employed creative group and peer supervisory models with his residents, placing them each in the supervisory position and the position of being supervised, as well as integrating process notes and A-V portions of the treatment itself. Roleplaying is occasionally used also. Consolidation of therapeutic gains in all brief dynamic treatments requires close attention to the termination phase. However, there is great variability among programs in the conceptualization and teaching of the termination phase, as there is also in the literature. Supervisory exercises that elucidate the important technical concerns of the termination would be welcomed. Educational Challenges: Integrating New Technology Most psychotherapists are unaware of the high-quality, home-based, two-way cable networks that operate, especially in the western part of the United States. Not only can such systems be used to teach diabetic care in the home, they can also be used to evaluate patients for psychotherapy and provide mechanisms for consultation about disruptive behavior in children and adults. They provide the potential for conducting most or all of a brief psychotherapy from long distance.38 Of greater importance is the possibility of multisite cable-based supervision for one psychotherapy program or a consortium of programs. In such a format, supervisors can model technique and maintain communication with supervisees through the use of immediate viewer response systems. Psychotherapy educators have trailed far behind other health care professionals in the development of compact disc multimedia interactive programs. These programs integrate actual clinical encounters with self-learning principles embedded in text. The Internet provides other opportunities for continuing education without the constraints of production delays associated with print material. Perhaps someday it may be possible to have the psychotherapist appear in the home of the patient as a hologram. (Shades of Star Warr the psychotherapist as the Force. ) C 0 N C I. U S I 0 N There has been a long-standing tradition within psychoanalysis and psychoanalytic psychotherapy of developing brief, effective therapeutic models. Given the breadth and depth of psychoanalytic theory, many of these heuristic approaches have held promise; however, few have been validated in the same fashion as other, nondynamic brief treatments. Lacking robust scientific data in both efficacy and treatment effectiveness, many brief dynamic therapies are under attack now from psychotherapy researchers, clinicians, and managed care organizations. At present it can be said that, as a group, the brief dynamic psychotherapies have received promising but limited support from research. Because the majority of all patient encounters, at least in American psychiatry, involve some form of psychotherapy, and many of these interventions are based on the principles of psychodynamic psychotherapy, the field must move forward and complete the research that will substantiate the helpfulness of brief dynamic approaches, either when used as the only intervention or in conjunction with other interventions such as medication. R E F E R E N C E 1. Alexander F, French TM: Psychoanalytic Therapy: Principles and Applications. New York, Ronald Press, Malan DH: The Frontier of Brief Psychotherapy. New York, Plenum, Mann J: Time-Limited Psychotherapy. Cambridge, MA, Harvard University Press, Sifneos P: Short-Term Dynamic Psychotherapy and Emotional Crisis. Cambridge, MA, Harvard Univer- VOLUME 6. NUMBER 4. FALL 1997

8 KAY 337 sity Press, Davanloo H: Short-Term Dynamic Psychotherapy. New York,Jason Aronson, Horowitz MJ: Stress Response Syndromes, 2nd edition. Northvale, NJ,Jason Aronson, Luborsky L: Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive (SE) Treatment. New York, Basic Books, Strupp HS, BinderJL: Psychotherapy in a New Key: A Guide to Time-Limited Dynamic Psychotherapy. New York, Basic Books, Garfield SL: The Practice of Brief Therapy. New York, Pergamon, Bellak L: Handbook of Intensive Brief and Emergency Psychotherapy, 2nd edition. Larchmont, NY, CPS, Gustafson JP: The Complex Secret of Brief Psychotherapy. New York, WW Norton, Benjamin LS: Use of structural analysis of social behavior to guide intervention in psychotherapy, in Handbook of Interpersonal Psychotherapy, edited by AnchinJC, Kiesler DJ. New York, Pergamon, 1982, pp Fosha D: The interrelatedness of theory, technique and therapeutic stance: a comparative look at intensive short-term dynamic psychotherapy and accelerated empathic therapy. International Journal of Short- Term Psychotherapy 1992; 7: WeissJ, SampsonJ: The Psychoanalytic Process: Theory, Clinical Observations and Empirical Research. New York, Guilford, Milrod B, Busch F, Cooper A, et al: Manual of Panic- Focused Psychodynamic Psychotherapy. Washington, DC, American Psychiatric Press, Klerman GL, Weissman MM, Rounsaville BJ, et al: Interpersonal Therapy of Depression. New York, Basic Books, Crits-Christoph P, Barber JP (eds): Handbook of Short-Term Dynamic Psychotherapy New York, Basic Books, Messer SB, Warren CS: Models of brief dynamic psychotherapy: a comparative approach. New York, Guilford, Roth A, Fonagy P: What Works for Whom: A Critical Review of Psychotherapy Research. New York, Guilford, Lazar SG: The effectiveness of psychodynamic psychotherapy for depression. Psychoanalytic Inquiry 1997; (suppl): Doidge N: Empirical evidence for the efficacy of psychoanalytic psychotherapies and psychoanalysis: an overview. Psychoanalytic Inquiry 1997; (suppl): Svartberg M, Styles TC: Comparative effects of shortterm psychodynamic psychotherapy: a meta-analysis. J Consult Clin Psychol 1991; 59: Cnts-Christoph P: The efficacy of brief dynamic psychotherapy: a meta-analysis. Am J Psychiatry 1992; 149: Orlinsky DE, Howard KI: Process and outcome in psychotherapy, in Handbook of Psychotherapy and Behavior Change, 3rd edtion, edited by Garfield SL, Bergin AE. New York, Wiley, 1986, pp Koss MP, ButcherJN: Research on brief psychotherapy, in Handbook of Psychotherapy and Behavior Change, 3rd edition, edited by Garfield SL, Bergin AE. New York, Wiley, 1986, pp Koss MP, ShiangJ: Research on brief psychotherapy, in Handbook of Psychotherapy and Behavior Change, 4th edition, edited by Bergin AE, Garfield SL. New York, Wiley, 1994, pp Howard KI, Kopta SM, Krause MS, et al: The doseeffect relationship in psychotherapy. Am Psychol 1986; 41: Kopta SM, Howard KI, LowiyJL, et al: Patterns of symptomatic recovery in psychotherapy. J Consult Chin Psychol 1994; 62: Nicholson RA, BermanJS: Is follow-up necessary in evaluating psychotherapy? Psychol Bull 1983; 93: Lambert MJ, Shapiro DA, Bergin AE: The effectiveness of psychotherapy, in Handbook of Psychotherapy and Behavior Change, 3rd edition, edited by Garfield SL, Bergin AE. New York, Wiley, 1986, pp BarberJP: Efficacy of short-term dynamic psychotherapy: past, present, future.j Psychother Pract Res 1994; 3: Weiss J: Unconscious mental functioning. Sci Am 1990; 262: Vaillant GE: Ego Mechanisms of Defense: A Guide for Clinicians and Researchers. Washington DC, American Psychiatric Press, Horowitz MJ, Milbrath C, Stinson CH: Signs of defensive control locate conflicted topics in discourse. Arch Gen Psychiatry 1995; 52: Stiles WB: Producers and consumers of psychotherapy research ideas.j Psychother Pract Res 1992; 1: Talley PF, Strupp HH, Butler SF (eds): Psychotherapy Research and Practice: Bridging the Gap. New York, Basic Books, Rodenhauser P: On the future of psychotherapy supervision and psychiatry. Academic Psychiatry 1996; 20: Kaplan EH: Telepsychotherapy: psychotherapy by telephone, videotelephone, and computer videoconferencing.j Psychother Pract Res 1997; 6: JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH