INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY OF SCHIZOPHRENIA

INDIVIDUAL PSYCHODYNAMIC PSYCHOTHERAPY OF SCHIZOPHRENIA Empirical Evidence for the Practicing Clinician William H. Gottdiener, PhD John Jay College of Criminal Justice of the City University of New York Practicing psychodynamically oriented clinicians need empirical evidence to support the use of individual psychodynamic psychotherapy for the treatment of individuals with schizophrenia. The purpose of this article is to provide psychodynamically oriented clinicians with that needed empirical evidence. A review of the meta-analytic research on the use of individual psychodynamic psychotherapy was conducted. It is concluded that strong empirical support exists for the use of individual psychodynamic psychotherapy in the treatment of schizophrenia. In addition, several suggestions are made to help clinicians apply the meta-analytic evidence to their daily clinical work. Limitations of the available evidence are discussed. Keywords: psychodynamic, psychotherapy, schizophrenia, meta-analysis, literature review Individual psychodynamic psychotherapy for people with schizophrenia once received considerable attention from the psychoanalytic community (see Karon & VandenBos, 1981, for an example). However, there has been a sharp decline in interest in schizophrenia within the field of psychoanalysis in recent decades (Willick, 2001). In fact, the topic of schizophrenia has been removed from the curriculum of most institutes of the American Psychoanalytic Association. Perhaps the decline in schizophrenia courses reflects a belief among psychoanalysts that individual psychodynamic psychotherapy provides little if any benefit to those with schizophrenia, a pessimism that has also been voiced by mainstream clinical psychiatry and psychology (see Lehman & Steinwachs, 1998; Mueser & Berenbaum, 1990). Some of the material for this article was adapted from Gottdiener and Haslam (2002). I thank Ann-Louise Silver and Nick Haslam for their constructive feedback on a draft of this article. Opinions expressed in this article do not necessarily represent the official positions of John Jay College of Criminal Justice or the City University of New York. Correspondence concerning this article should be addressed to William H. Gottdiener, PhD, Department of Psychology, John Jay College, 445 West 59th Street, New York, NY 10019. E-mail: wgottdiener@jjay.cuny.edu Psychoanalytic Psychology, 2006, Vol. 23, No. 3, 583 589 Copyright 2006 by the American Psychological Association, 0736-9735/06/$12.00 DOI: 10.1037/0736-9735.23.3.583 583

584 BRIEF REPORT Close examination of the psychotherapy outcome literature reveals that pessimism about the utility of individual psychodynamic psychotherapy for the treatment of schizophrenia is unfounded. Meta-analytic research has found that individual psychodynamic psychotherapy is associated with significant improvement in individuals with schizophrenia (Gottdiener & Haslam, 2002). In the current article, I review the meta-analytic evidence supporting the psychodynamic treatment of schizophrenia and suggest how practicing clinicians can use this evidence and apply it in their daily clinical work. Research Into Individual Psychodynamic Psychotherapy for Schizophrenia Despite the considerable attention once given to the treatment of schizophrenia by the psychoanalytic community, misgivings about the efficacy of psychoanalytic treatments for schizophrenia have haunted the field of psychoanalysis since Sigmund Freud voiced them more than 100 years ago (Freud, 1904). Nonetheless, psychodynamic treatments for schizophrenia prospered and evolved, and they have been used for more than a century. As mentioned earlier, their efficacy remains contentious in clinical psychoanalysis (Gottdiener, 2002; Robbins, 2002; Willick, 2002) and in mainstream clinical psychiatry and psychology (Lehman & Steinwachs, 1998; Mueser & Berenbaum, 1990). Despite the controversy, a large clinical literature has accrued. Most of this literature describes creative interventions that psychotherapists have developed to achieve positive results. Some of the more prominent psychotherapists are Arieti (1974), Boyer and Giovacchini (1980), Federn (1952), Fromm-Reichmann (1950), Karon and VandenBos (1981), Lotterman (1996), Pao (1979), Robbins (1993), Searles (1965), and Sullivan (1962). In contrast to the clinical literature, research on the efficacy of individual psychodynamic psychotherapy for people with schizophrenia has produced contradictory findings. Two frequently cited, and now classic, studies exemplify these mixed results (Karon & VandenBos, 1981; May, 1968). Both were randomized controlled clinical trials (RCTs) comparing individual psychotherapy with and without antipsychotic medication to standard treatment in which medication was the primary intervention. May found that inpatients treated solely with medication and those treated with individual supportive psychodynamic psychotherapy and conjoint antipsychotic medication had significantly greater improvement rates than patients who received only supportive psychodynamic psychotherapy. In the Karon and VandenBos study, also conducted in the 1960s, the opposite was found. Psychotherapists treated two groups of patients with individual exploratory psychodynamic psychotherapy. One group did not receive medication and the other did, but only in small doses that were ended within the first few weeks of treatment. These two treatment groups were compared with a third group of patients who received standard hospital care, with antipsychotic medication as the primary treatment. Significantly more patients who were treated with individual psychotherapy (including those receiving a brief course of medication) improved compared with those patients who received medication only. Since the publication of these two landmark studies, many others have been conducted. The results of these studies have been summarized in a number of reviews (Fenton, 2000; Gomes-Schwartz, 1984; Gottdiener & Haslam, 2002; Heinrichs & Carpenter, 1981; Lehman & Steinwachs, 1998; Liberman, 1994; Mojtabai, Nicholson, & Carpenter, 1998; Malmberg & Fenton, 2001; Mosher & Keith, 1980; Mueser & Berenbaum, 1990; Scott & Dixon, 1995; Smith, Glass, & Miller, 1980).

585 The Utility of Meta-Analytic Methods Meta-analysis is the quantitative synthesis of similar empirical reports. Although, as with all statistical techniques, meta-analysis is not without its limitations (see LeLorier, Gregoire, Benhaddad, Lapierre, & Derderian, 1997; Wilson & Rachman, 1983), it is the most effective way to resolve controversial findings across a body of literature and has distinct advantages over qualitative literature reviews (see Gottdiener & Haslam, 2002, p. 165; Hunter & Schmidt, 1990; Rosenthal, 1991). Meta-Analytic Evidence Against Individual Psychodynamic Psychotherapy The Cochrane Review Group is a research organization in the United Kingdom that sponsors systematic and meta-analytic literature reviews of empirical treatment literature. The group s purpose is to determine the efficacy of a wide range of medical treatments that have been researched using RCTs. The group has become highly regarded for its efforts. In 2001, Malmberg and Fenton published a review of RCTs of individual psychodynamic psychotherapy for individuals with schizophrenia under the auspices of the Cochrane Review Group. The authors claimed that only three reports existed that used an RCT design and that the methods of existing research were too poor to draw definitive conclusions for or against the efficacy of individual psychodynamic psychotherapy in inpatient settings. In the end, they simply called for more research to be done. Meta-Analytic Evidence in Support of Individual Psychotherapy In 1998, Mojtabai et al. published a comprehensive meta-analysis that reviewed all studies of psychosocial and psychotherapeutic treatments for schizophrenia that were concurrently combined with antipsychotic medication. In addition, all of the studies that they included in their meta-analysis consisted of RCTs in which the experimental treatment consisted of a psychosocial or psychotherapeutic treatment that was delivered with concomitant antipsychotic medication. The comparison treatment consisted of standard treatment or treatment as usual with concomitant antipsychotic medication used as the primary treatment. Mojtabai et al. found that psychosocial and psychotherapeutic treatments that were combined with antipsychotic medication produced significantly better outcomes compared with standard treatment. Furthermore, individual psychotherapy produced the largest effect sizes. However, the authors reported that no conclusions could be reached about the efficacy of individual psychodynamic psychotherapy. The likely reason for this is that the authors reviewed only 10 studies of individual psychotherapy, few of which were psychodynamically oriented treatments. Meta-Analytic Evidence in Support of Psychodynamic Psychotherapy for Schizophrenia The earliest meta-analytic evidence supporting the use of psychodynamic psychotherapy for psychotic disorders comes from Smith et al. (1980). In their meta-analysis, they reported the results of the mean effect size for all forms of psychodynamic psychotherapy (individual, group, family) when combined with antipsychotic medication for schizophrenia. They meta-analyzed studies that compared psychotherapy

586 BRIEF REPORT plus medication with medication plus standard treatment (which did not include psychotherapy). Smith et al. found that psychodynamic psychotherapy plus medication produced a significantly greater improvement compared with medication plus standard treatment. Meta-Analytic Evidence in Support of Individual Psychodynamic Psychotherapy for Schizophrenia In 2002, my colleague Nick Haslam and I published the first, and to date only, metaanalysis to specifically determine the effects of individual psychotherapy for people with schizophrenia (Gottdiener & Haslam, 2002). In that meta-analysis, we investigated psychodynamic, cognitive behavioral, and nonpsychodynamic supportive therapies. We found that all three treatments were associated with significant overall improvement and that psychodynamic and cognitive behavioral therapies produced similar effect sizes. More specifically and germane to the discussion at hand, individual psychodynamic psychotherapy was associated with an overall moderate effect size of r.33 (95% CI.21 to.44) (Gottdiener & Haslam, 2002, p. 173). This means that with treatment, 67% of individuals will improve compared with 34% of those who do not receive treatment (see Rosenthal, 1991, for the method used to determine the percentage improved as a result of treatment). Furthermore, individual psychodynamic psychotherapy was associated with significant improvements when used with medication and even when used without medication. None of the other treatments had been tested without medication. Furthermore, all individual psychotherapies were associated with similar effects for chronic and acute schizophrenia and for studies that used random assignment of participants and those that did not use random assignment. Treatment of outpatients was associated with greater improvement compared with treatment of inpatients. Finally, participants who were diagnosed using Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; American Psychiatric Association [APA], 1980) criteria actually showed greater overall improvement in functioning than those who were diagnosed with earlier, broader diagnostic criteria. Application of Meta-Analytic Evidence to Clinical Practice It should be clear from the foregoing review of previous meta-analytic research that individual psychodynamic psychotherapy can play an important role in the treatment of people with schizophrenia. This opinion is based not on clinical anecdotes but on empirical research. The meta-analytic evidence is useful in justifying the use of individual psychodynamic psychotherapy for schizophrenia as an empirically supported treatment to other colleagues, to insurance companies, to clients, and to one s self. The meta-analytic evidence might also be used by the practicing psychotherapist as reassurance that individual psychodynamic psychotherapy can benefit individuals with schizophrenia. Knowing that there is empirical evidence to support a clinical treatment plan can be especially encouraging to therapists to help them stay the course of what is inevitably a difficult form of treatment to implement effectively. Finally, treatment plans of individual psychotherapy for people with schizophrenia can be written from the perspective that, on average, most patients will improve significantly over time.

587 Discussion The foregoing review provides meta-analytic evidence that strongly supports the use of individual psychodynamic psychotherapy for people with schizophrenia. Despite the strong evidence, there are fewer than 30 studies of individual psychodynamic psychotherapy for the treatment of schizophrenia. Therefore, many more RCTs of individual psychodynamic psychotherapy for the treatment of schizophrenia are needed (Malmberg & Fenton, 2001; Roth & Fonagy, 2005). The evidence presented in this article provides empirical muscle for a large body of psychodynamically oriented clinical literature that exists for the treatment of schizophrenia (see Gottdiener & Haslam, 2002; see also Karon & Teixeira, 1995, and Lotterman, 1996, for a discussion of psychodynamic therapeutic techniques that can be used in the treatment of schizophrenia). The practicing clinician can use the meta-analytic information to support a clinical choice of using individual psychodynamic psychotherapy for the treatment of schizophrenia. However, it should be clear that effective practice of this treatment requires prolonged study of the clinical literature and closely supervised training under the guidance of an experienced psychotherapist who has successfully treated people with schizophrenia. Furthermore, it is important to keep in mind that the empirical evidence from treatment outcome studies suggests what the overall mean outcome is likely to be. The evidence does not indicate whether any one specific patient will improve. If improvement occurs, the evidence does not allow the clinician to predict which symptoms will change, how quickly, or by how much. In the future, single-case time-series research might be used to answer these important clinical questions (see Borckardt & Nash, 2002). It should be noted that the meta-analytic results discussed in this article are not consistent with the schizophrenia treatment guidelines of the APA (2004). However, it should also be pointed out that the APA guidelines were not created by synthesizing the empirical literature using meta-analytic methods. Instead, they were created primarily by using qualitative literature review methods, which have significant limitations compared with meta-analysis (Hedges & Olkin, 1985; Hunter & Schmidt, 1990; Lipsey & Wilson, 2001; Rosenthal, 1991) and which have been shown to produce erroneous conclusions compared with those of meta-analytic methods (Cooper & Rosenthal, 1980). Therefore, based on the evidence presented here, the practicing psychodynamically oriented clinician who chooses to treat individuals with schizophrenia should be encouraged that good evidence exists to support that treatment choice. References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (2004). Practice guideline for the treatment of patients with schizophrenia (2nd ed.). Washington, DC: American Psychiatric Association. Arieti, S. (1974). Interpretation of schizophrenia. New York: Jason Aronson. Borckardt, J. J., & Nash, M. R. (2002). How practitioners (and others) can make scientifically viable contributions to clinical outcome research using the single-case time-series design. The International Journal of Clinical and Experimental Hypnosis, 50(2), 166 200. Boyer, L. B., & Giovacchini, P. L. (1980). Psychoanalytic treatment of schizophrenic, borderline, and characterological disorders (2nd ed.). New York: Jason Aronson. Cooper, H. M., & Rosenthal, R. (1980). Statistical versus traditional procedures for summarizing research findings. Psychological Bulletin, 87, 442 449.

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