Academic journal article International Journal of Psychoanalysis

How to Measure Sustained Psychic Transformations in Longterm Treatments of Chronically Depressed Patients: Symptomatic and Structural Changes in the LAC Depression Study of the Outcome of Cognitive-Behavioural and Psychoanalytic Long-Term Treatments *

Academic journal article International Journal of Psychoanalysis

How to Measure Sustained Psychic Transformations in Longterm Treatments of Chronically Depressed Patients: Symptomatic and Structural Changes in the LAC Depression Study of the Outcome of Cognitive-Behavioural and Psychoanalytic Long-Term Treatments *

Article excerpt

Introduction

The question of whether and in what way psychoanalysis should undergo comparative outcome studies has remained controversial in the psychoanalytic community. It is primarily psychoanalytic researchers at medical and psychological faculties who argue that psychoanalysis will be marginalized if it avoids comparing its effectiveness with other treatments, while psychoanalysts, particularly those from the French-speaking world, insist that methods and criteria of evidence-based medicine are unsuitable for psychoanalysis as a science of the unconscious. In spite of these ongoing controversies, the third edition of the Open Door Review shows that more studies of process and outcome have become available, indicating that the acceptance of empirical research is increasing in the International Psychoanalytic Association (Leuzinger-Bohleber and Kaechele 2015).

In certain countries, such as Germany, the risk is growing that funding for psychoanalysis and psychodynamic treatments by health insurance companies will be withdrawn if their effectiveness cannot be demonstrated using conventional Randomized Controlled Trial (RCT) outcome studies. In 2015, the German Scientific Advisory Board for Psychotherapy first assessed the findings of outcome studies of behavioural therapy for a range of mental disorders. In 2018, psychoanalytic treatments will be subject to a similar evaluation.

This scrutiny and questioning of the effectiveness of psychoanalysis was one of the reasons why a German psychoanalytic research group, together with a well-respected cognitive-behavioural therapist and researcher, decided to undertake a multicentre study on the outcome of cognitive and psychoanalytic long-term treatments with chronically depressed patients in 2005.

By then, meta-analyses had indicated efficacy for cognitive-behavioural and psychodynamic short-term therapies, but evidence on the effectiveness of longer-term treatments was limited (Fonagy 2001; Leichsenring 2001). At the same time, in some patient groups, e.g. chronically depressed, the tremendously high relapse rate of any form of short-term therapy became apparent (Blatt and Zuroff 2005). There is a consensus among clinicians that these patients require long-term treatment in order to achieve a lasting improvement in their condition and to minimize the risk of a permanent disability (see e.g. Blomberg at el, 2001; Clarkin et al., 2007; Doering et al., 2010; Driessen et al, 2010).

Moreover, methodological objections were made to the exclusive use of RCTs to compare the results of different kinds of short-term therapy: they do not correspond to the parameters of actual practice and thus their results have limited validity (c.f., among others, Westen, Novotny, and Thompson-Brenner 2004; Blatt and Zuroff 2005; Westen et al. 2006); success is measured according to simplified, uniform measures of symptoms that may bias towards pharmacological or behavioural approaches while being less suited to the mode of action of psychoanalytic approaches; the patients' own assessments and preferences hardly get attention, and so on. Arguments of scientific theory were also expressed: comparative psychotherapy research in effect was promulgating a methodological myth about the uniformity of science as well as of clinical practice (Hampe 2003; Leuzinger-Bohleber, Dreher, and Canestri 2003); it was applying research designs suitable for pharmacology to the field of psychotherapy research in a way that was not justified either theoretically, practically or scientifically. Furthermore, psychotherapeutic concerns are subjected to economic evaluations in times of the economization of health care.

The planning and implementation of the Long-term treatments of chronically depressed patients (LAC) study took place against the backdrop of these controversial discussions. Therefore, our research group opted for a design that combines a naturalistic with an experimental study. In contrast to many studies of comparative psychotherapy research, in which, for methodological and pragmatic reasons, trained students or study therapists treated persons with precisely defined symptoms (often students) according to a manualized therapy method, in the LAC study, chronically depressed patients, as they attend the private practices of psychotherapists in Germany today, were treated by experienced therapists in long-term psychotherapies. …

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