THE

AMERICAN

The

Efficacy

JOURNAL

OF PSYCHIATRY

Special

Articles

of Brief

Dynamic

Psychotherapy:

A Meta-Analysis Paul Crits-Christoph,

Objective: concerned apy

with

Insurance efficacy

is a primary

target

is a meta-analytic Method: puterized

companies, legislators, and and accountability in regard ofconcern

review

ofrecent

because

Eleven

studies

therapy therapy

met

the inclusion

as represented and a waiting

apy, sary

for

and

experienced

practiced

studies

in outpatient

ofthe

efficacy

criteria:

use

of a specific

form

or manual-like nonpsychiatric

settings.

This

ofbriefdynamic

paper

therapy.

of short-term

therapy.

The

outcome

dynamic

psycho-

guide; comparison of brief dynamic treatment, alternative psychother-

or other form of dynamic therapy; provision ofeffect sizes; at least 1 2 therapy sessions; and in briefdynamic

have become increasingly andpsychodynamic ther-

both published studies, located through an extensive cornpsychology journals, and studies reported at conferences.

in a treatment manual list control condition,

pharmacotherapy, calculation

funding agencies to psychotherapy,

it is widely

well-controlled

The meta-analysis included search of psychiatry and

Ph.D.

measures

of the information therapists who were compared

were

target

necestrained syrnp-

toms, psychiatric symptoms generally, and social functioning. Results: Brief dynamic therapy demonstrated large effects relative to waiting list conditions but only slight superiority to nonpsychiatric treatments. Its effects were about equal to those ofother psychotherapies and medication. Conclusions: These data confirm previous indications that various psychotherapies do not differ in effectiveness, although this finding should not be generalized to all patient populations, studies lengths, (Am

O ingly

outcome

measures,

and

limit conclusions about follow-up assessments,

J Psychiatry

1992;

treatment

with

efficacy

J

Psychiatry

149:2,

February

the

highly

controlled

conditions

studies should address patient groups, and

various outcome

of these treatment measures.

149:151-158)

and accountability

legislaincreas-

in re-

Received Feb. 8, 1991; revision received June 17, 1991; accepted July 16, 1991. From the Department of Psychiatry, School of Medicine, University of Pennsylvania. Address reprint requests to Dr. CritsChristoph, 301 Piersol Bldg., Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Supported in part by NIMH Clinical Research Center grant MH45178, grant MH-40472, and Career Development Award MH00756 to Dr. Crits-Christoph. Copyright © 1992 American Psychiatric Association.

Am

Also,

actual practice. Future and specific treatments,

ver the past decade, insurance companies, tors, and funding agencies have become

concerned

types.

1992

gard

to psychotherapy

(1

).

Psychodynamic

therapy,

be-

cause it is widely practiced in outpatient settings, is a natural target for such concerns about efficacy. Although there have been a number of reviews of the literature on the efficacy of psychotherapy in general (2, 3) and the efficacy of specific treatments (4, 5), few reviews have been devoted to the efficacy of psychodynamic therapy in particular. An obvious reason for this is the relative dearth until recent years of well-controlled studies of the outcome of dynamic psychotherapy. In addition, a vanety of methodological problems hindered the interpretation of results from earlier studies.

151

BRIEF DYNAMIC

THERAPY

Perhaps the greatest problem with many efficacy studies of dynamic therapy has been the lack of control and specification of the treatment variable. The improvements in outcome research due to the use of treatment manuals and careful selection, supervision, and monitoring of therapists are relatively recent (6). Many otherwise well-controlled studies of the efficacy of dynamic therapy (e.g., 7-10) left unanswered questions about the meaning of the findings because the nature of the treatment provided by dynamic therapists was not cleanly specified and controlled. These studies in general allowed dynamic therapists to conduct treatment as they usually practiced, on the assumption that differing orientations and styles among dynamic therapists are of little concern. Although such naturalistic treatment studies perhaps generalize better to the eclectic practice of dynamic therapy as it actually occurs, necommendations about specific treatment approaches cannot be based on such studies. In addition, recent evidence (1 1 ) indicates that studies which do not use treatment manuals are much more prone to therapist effects (i.e., significant differences between therapists in outcomes) than are studies which do use treatment manuals. Such therapist effects create a statistical problem of nonindependence, which can lead to highly distorted conclusions about the efficacy of treatments when ignored in the analysis of comparative outcome data (as is typically the case) (12). Thus, many of the findings from studies of dynamic therapy that did not use manuals are questionable on statistical grounds and do not provide clear clinical recommendations because of the eclectic treatment. Moreover, although the use of a dynamic therapy treatment manual does not necessarily lead to greaten treatment benefits, the more careful selection, training, and monitoring of therapists in the recent comparative studies using manuals are likely to provide the highest quality of treatment possible. In the area of brief dynamic therapy, a number of specific dynamic approaches have now been articulated in the form of guides or manuals to be used in the training of therapists: Luborsky (13), Strupp and Binder (14), Sifneos (15), Davanloo (16), Mann (17), Horowitz (18), and others. Although not all of these books have been labeled “manuals,” what they have in common are a clearly laid out theory, detailed case examples, and a set of technical recommendations for the practice of a particular dynamic therapy (1 9). In addition, these guides lend themselves well to use in a research context, and studies implementing these approaches are beginning to accumulate. Because of these improvements in outcome research, I was able to conduct a meta-analytic review (20) of the evidence for the efficacy of short-term dynamic therapy, attending only to studies that controlled the treatment variable through the use of a manual or manuallike guide for therapists. Three main questions were addressed: 1) To what extent is there evidence that brief dynamic therapy is more effective than no treatment? 2) How does brief dynamic therapy compare to regular contact with patients that is not standard psychiatric

152

treatment?

and

compare

to

cluding

3) How

other

medication

forms

does of

brief

dynamic

psychiatric

and nondynamic

therapy

treatment,

in-

psychotherapies?

In addition to summarizing the literature on these questions, I will make recommendations about future research that would advance this area of study.

METHOD Selection

of Studies

To qualify for this review, a study had to test the efficacy of a specific form of short-term dynamic therapy as represented in a treatment manual or manual-like guide. Studies comparing brief dynamic therapy to a waiting list control condition, a nonpsychiatnic treatment, an alternative psychotherapy, pharmacotherapy, or another form of dynamic therapy (or some combination of these comparison conditions) were included. In addition, only reports that included the information necessary for the calculation of effect sizes (discussed later) were included. The review was not restricted to published studies but included studies that had been presented at conferences. The published studies were found through an extensive computerized search of

psychiatry

and psychology

Any study that analogue study)

shortest

study

journals.

did not involve was excluded

accepted

a patient from the

for the review

was

group review.

(e.g., The

the 12-ses-

sion

treatment described by Mann (17). Also excluded from the review were studies that used therapists who were not specifically trained and experienced in brief dynamic therapy techniques. This excluded studies which

either

used

trainees

or

used

experienced

thera-

pists who had not received training in short-term dynamic therapy. This criterion was chosen because most therapists with a psychodynamic orientation tend to adhere to long-term treatment and are slow to adapt to the philosophy of short-term therapies (21). The 1 1 studies that met the inclusion criteria are listed in table 1 with the type of patients, treatment conditions, number of patients in each condition, and length of therapy for each study. These studies included tests of the efficacy of the brief dynamic treatments described by Mann (17), Davanloo (16), Luborsky (13), Horowitz (18), Pollack and Homer (32), Strupp and Binder (14), Malan (33), and Klerman, Weissman,

Rounsaville,

and

Chevron

(34).

The

interpersonal

ap-

proach of Klerman et al., although less like other dynamic therapies in that the relationship with the therapist is not generally a focus of intervention, was included because of its historical roots in the work of Sullivan. In addition, the NIMH Treatment of Depression Collaborative Research Program (35) identified the interpersonal approach as generally within the psychodynamic domain, and psychodynamically oriented therapists were selected to perform the treatment in that study. The 11 studies typically had a training period for

Am/Psychiatry

149:2,

February

1992

PAUL

TABLE

1. Studies

of the Efficacy

of Brief Dynamic

Authors Mixed

Shefler and Dasberg (unpublished, 1989) Elkin et al. (23)

Mixed

Rounsaville

Opiate

Winston

Treatment

et al. (25)

addiction

Personality disorders

et al. (26)

Depression

Brom et al. (27)

Posttraumatic stress disorder

DiMascio

Depression

et al. (28)

Carroll

et al. (29)

Cocaine

abuse

Woody

et al. (30)

Opiate

addiction

Marmar

Ct

al. (31)

number number

Pathological

of sessions of sessions

grief

Measures

Rather

namic tions: specific

than

therapy I ) Does target

asking

the broad

question,

work? I asked three short-term dynamic symptoms

Does

brief

dy-

more specific questherapy affect the

or problem

areas

for

which

patients are seeking treatment? 2) Does short-term dynamic therapy change the general level of psychiatric symptoms, and 3) Does short-term dynamic therapy improve social functioning? The goal of this meta-analytic review was, as much as possible, to assess the effects of brief dynamic therapy

Am

J

Psychiatry

N 48 57 16 17 47 37 37 35 22 28 IS 17 I7 30 31 30 29 31 29 23 17 20 21 21 21 32 39 35 31 30

Treatment

I 49:2,

February

1992

Length

Mean=18.6 sessions S months Mean=12 sessions 3 months Mean=16.2 sessionsa Mean=16.2 sessionsa Mean=16.2 sessionsa Mean=16.2 sessionsa Mean=13.2 1 session/month for 6 months1’ 40 sessions 40 sessions S months 16-20 sessions 16-20 sessions 16-20 sessions Mean=1 8.8 sessions Mean=1 S sessions Mean=14.4 sessions 4 months Mean=16 sessions Mean=16 sessions 1 session/month 12 sessions I 2 sessions Mean=12 sessions Mean=9.S sessions Mean=17 sessions Mean=12 sessions Mean=12 sessions

for all patients who completed the study; data were not broken down by treatment group. not reported, but data on dropouts suggest low-contact patients attended a mean of approximately

therapists before the actual outcome study, but, as indicated in the selection criteria, they did not use inexperienced therapists. On the contrary, most studies used highly experienced therapists. In four studies the average length of postgraduate clinical experience was more than 9 years. Four other studies listed only the minimum number of postgraduate years required for therapists who participated in the study (typically 2 years). One study used therapists who were not only experienced clinicians but also had supervised training in the particular form of brief dynamic therapy for 2 years before the start of the study. Another study employed therapists who had on the average 5.5 years of experience in working with the types of patients studied. One study did not specify the therapist experience level other than to say “an experienced psychiatrist.” Outcome

Conditions

Dynamic Waiting list Dynamic Waiting list Interpersonal Cognitive Imipramine Placebo and clinical management Interpersonal Low-contact Dynamic-Davanloo Dynamic-Pollack and Homer Waiting list Dynamic Cognitive Behavioral Dynamic Desensitization Hypnotherapy Waiting list Interpersonal Amitriptyline Low-contact Interpersonal Relapse prevention Dynamic Cognitive Drug counseling Dynamic Self-help

Depression

et al. (24)

Thompson

aMean bMean

Psychotherapy

Disorder

Piper et al. (22)

CRITS-CHRISTOPH

four sessions.

on specific outcome measures. Since different outcome measures may vary in their reliability and sensitivity to change (36), it has been recommended (37) that metaanalyses not combine information on different outcome measures. Although the practice of combining information on heterogeneous outcome measures was common in early meta-analyses (e.g., 2), more recent meta-analytic reviews (e.g., 5) have begun to focus on specific measures. In selecting measures that could provide answers to my three questions, I had to chose measures that were available in most studies. To assess specific target symptoms or problem areas for which patients seek treatment, I examined two forms of outcome measures. For studies of heterogeneous patient groups, the target complaints method (38) was selected. This measure requires the patient to rate the severity of the three main problems for which he or she is seeking treatment. For studies that investigated dynamic therapy for a specific patient group (e.g., cocaine abusers), the main problem area was already defined by the nature of patient selection. In these studies, a measure of the severity of this particular problem area or disorder (e.g., the Beck Depression Inventory for depressed patients) was selected to represent change in target symptoms. To answer the question about the effect of brief dynamic therapy on general levels of psychiatric symptoms, the SCL-90 (39) was chosen. The Social Adjustment Scale (40) was selected to assess social functioning. In each of

153

BRIEF

DYNAMIC

TABLE

2. Effect

ThERAPY

Sizes for Comparisons

of Brief Dynamic

Psychotherapy

and Other Treatment

Conditions Average

Condition Compared With Brief Dynamic Psychotherapy

Number of Comparisons

Waiting list control Alternative nonpsychiatric treatments Alternative psychiatric treatments Other dynamic therapy aCalculated

according

to the method

S

of Cohen

Size

-0.25

0.81 0.09 -0.05 0.04

(41).

apy patient was better off than 84% of the comparison group patients. As an aid in interpreting effect sizes, Cohen (41 ) provided benchmarks for his d statistic. A value of 0.2 represents a small effect for the behavioral sciences, 0.5 a medium effect, and 0.8 a large effect. I will present alternative views of the meaning of different effect sizes in the Conclusions section.

RESULTS

Table

2 presents

of brief

dynamic

Waiting

List

the effect therapy

sizes

from

and the other

the comparisons conditions

tested.

Calculations

The primary defining characteristics of a meta-analysis are the calculation of effect sizes and the integration of these effect sizes across studies. For this study the calculation of effect sizes was guided by Cohen (41) and used his d statistic. Effect size was calculated as the posttreatment mean of the dynamic treatment group minus the posttreatment mean of the comparison group, divided by the standard deviation of the cornparison group. In some cases, only the adjusted posttreatment means and standard deviations (adjusted for initial levels) were available, and these were used instead of the raw means. A pooled standard deviation (across treatment groups) was used when the standard deviation for the comparison group was not available. Effect size calculated this way can be readily interpreted as the distance, in standard deviation units, that the average brief dynamic therapy patient was from the average comparison group patient. An effect size of zero indicates that the dynamic therapy and comparison groups were equal in outcome. All calculations were made so that a positive effect size indicates superiority of brief dynamic therapy and a negative effect size indicates superiority of the comparison condition. Thus, an effect size of 0.50 would indicate that the improvement of the average dynamic therapy patient was one-half of the standard deviation more than that of the average comparison group patient. Because the effect size is in units of standard deviations, it can be converted directly into a percentage representing nonoverlap of the distributions (41 ). For example, an effect size of 1 .00 would indicate that the average dynamic ther-

1S4

Social Adjustment

0.82 0.20 -0.01 0.05

-0.05

9 I

Size (d)a

General Psychiatric Symptoms

1.10 0.32

5

the few cases where these measures were not discussed in the published version of the study, the original investigators were contacted and asked to provide data on the measure if it was used in the study. In two studies the Social Adjustment Scale was not used, but ratings on alternative measures of social functioning were available, and change on these other instruments was evaluated for this review. If no measure of the construct was available, no effect size was calculated. In general, only assessments of outcome done at or near the termination of treatment were used for this review. Although it might be of interest to examine the effects of dynamic therapy some time after termination, since delayed effects might be expected, not enough reports of follow-up data are available yet. Effect

Target Symptoms

Effect

Five comparisons, from four studies (22, 25, 27, Shefler and Dasberg), are included in the results shown in table 2. The effect size for target symptoms is especially large, has been reported in previous studies (e.g., 42), indicating that these measures are particularly sensitive to change. When the effect sizes are translated into percentages, the data indicate that in terms of target symptoms the average brief dynamic therapy patient was better off than 86% of the waiting list patients. In terms of general symptoms (SCL-90), the average brief dynamic therapy patient was better off than 79% of the waiting list patients. For social adjustment, the average brief dynamic therapy patient was also better off than 79% of the waiting list patients. Nonpsychiatric

Treatments

Five studies compared brief dynamic therapy to some form of comparison condition that was not a standard psychiatric treatment modality (i.e., not medication or an alternative psychotherapy). The expectation in all of these studies was that dynamic therapy would produce greater effects than the comparison conditions. These comparison conditions ranged from the placebo and clinical management condition of the NIMH Treatment of Depression Collaborative Research Program study (23) to standard drug counseling (30), mutual self-help groups (31), and two studies employing a low-contact treatment (24, 28). Overall, the average effect sizes indicate little difference

between

the outcomes

Am

of brief dynamic

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I 49:2,

therapy

February

and these

1992

PAUL

comparison conditions. The largest average effect was for target symptoms, indicating that the average dynamic therapy patient was better off than 62% of the comparison group patients. The average effects, however, may be misleading, as there is considerable variation among these studies, perhaps as a result of the various types of comparison conditions, patient groups, etc. The effect sizes were fairly large in two studies, i.e., a comparison of the effects of dynamic therapy and drug counseling (30) on general psychiatric symptoms (effect size=O.74) and a comparison of the effects of interpersonal therapy and low-contact therapy (28) on target symptoms (effect size=O.67). In addition, in three of the five studies there was a much higher dropout rate from the alternative treatment than from dynamic therapy. Other

Psychiatric

Treatments

Six studies (23, 26-30) yielded nine comparisons of brief dynamic therapy and other standard psychiatric treatments. The alternative treatments included medication and various cognitive and behavioral therapies. The predominant trend is clear: only small differences between brief dynamic therapy and other treatments are generally apparent. No individual study effect size was greater than 0.30. The single comparison (25) of one form of dynamic therapy (Davanloo approach) with another (Pollack and Homer’s brief adaptation therapy) yielded no evidence for the superiority of one treatment.

CONCLUSIONS Meaning

of Effect

Sizes

The effect sizes shown by this analysis can be described as large according to Cohen’s definition (41). The translation to percentages communicates even more directly the extent to which a patient is much better off receiving dynamic therapy than no treatment. These effects are somewhat larger than the effect size (0.68) presented by Smith and Glass (2) for the general effects of psychotherapy. The heterogeneous treatments and control conditions used by Smith and Glass, however, may account in part for this difference. Alternatively, it is possible that the more recent studies reviewed here, which controlled the delivery of treatment to a greater extent, demonstrated larger changes than did the naturalistic assessments of dynamic therapy in the past. In addition to Cohen’s definitions, the magnitude of the effects of dynamic therapy can be understood through comparison with other types of interventions in medicine. Rosenthal (43) has performed such comparisons using the Smith and Glass meta-analysis (2). He demonstrated that the 0.68 effect size found by Smith and Glass was larger than the effect sizes for several well-known clinical trials in medicine which were halted before completion because it was decided the ef-

Am

J Psychiatry

149:2,

February

1992

CRITS-CHRISTOPH

fect was large enough that it would be unethical to withhold from some patients a clearly efficacious treatment. As mentioned, the effect sizes for dynamic therapy versus waiting list control conditions found here were even larger than the effect size reported by Smith and Glass. Obviously, with aspects of patient care that involve death or serious illness, even a small treatment effect might be deemed to be especially important. Nevertheless, it is informative to see that the effects of brief dynamic therapy (and psychotherapies in general) are strong in comparison to the effects of such medical treatments. Other forms of psychotherapy (besides dynamic) were not compared to waiting list control conditions in this investigation. Dobson (5) reported an average effect size of 2.15 (based on Beck Depression Inventory scores) for comparisons of Beck’s cognitive therapy to a waiting list or no treatment for depression. Although

this value

is substantially

larger

than the effect

sizes re-

ported here for comparisons of brief dynamic therapy and waiting list conditions, there is as yet no direct evidence for superiority of cognitive therapy, because the two studies that directly compared a manual-based dynamic or interpersonal therapy to cognitive therapy for the treatment of depression (23, 26) showed no differences between these treatments. It is likely that depression is a condition that responds well to treatments and that this accounts for the large effect size reported by Dobson (5) for comparisons of cognitive therapy to a waiting list and to no treatment. The data reported here on dynamic therapy’s lack of superiority to other standard psychiatric treatments are perhaps not surprising in light of previous reviews of the psychotherapy literature which have shown that various treatments do not differ in their effectiveness (2, 3). The fact that these conclusions hold up in studies where the treatment variable has been standardized and controlled through the use of treatment manuals is, however, still noteworthy. Although this finding appears robust, it is probably unwarranted to generalize this conclusion across all patient populations, outcome measures, and treatment types. For example, brief dynamic therapy has yet to be compared with exposure and response prevention in the treatment of obsessivecompulsive disorder. It is conceivable that, given the documented success of this behavioral treatment, exposure and response prevention would be shown to be superior to dynamic therapy on measures of compulsive behaviors. In brief, these unresearched questions are still unanswered. Despite the strong effects in the comparisons of brief dynamic therapy and waiting list control conditions, there was less evidence for brief dynamic therapy’s superiority to other treatment conditions that were not standard psychiatric treatments. Some studies, however, did yield evidence of superior efficacy. Moreover, in several studies there were higher dropout rates with the alternative treatments than with dynamic therapy. However, given the variation in the findings and the

155

BRIEF DYNAMIC

THERAPY

diverse nature of the control conditions and patient groups, it is difficult to draw meaningful conclusions from this small set of studies. Clearly, more research is needed to assess whether brief dynamic therapy is more beneficial than drug counseling, self-help groups, and the like. The rigorous requirements (such as careful selection, training, supervision, and monitoring of therapists and the use of treatment manuals) that have been implemented in psychotherapy outcome research and were used as criteria for selection of the studies reviewed here may limit the generalizability of the findings to the outpatient practice of dynamic therapy. On the one hand, the careful selection and supervision of therapists is

likely

to ensure

that

a high-quality

service

is delivered;

on the other hand, therapists in practice are not bound by a particular treatment guide or manual. Therapists in practice would therefore have more flexibility in their clinical work, which could conceivably lead to more favorable outcomes. Thus, what is gained in knowledge about the use of specific treatments under controlled conditions might also be a loss in terms of generalizability to the actual current practice of dynamic psychotherapy. Not only were the studies reviewed here performed under highly controlled conditions, but some of the forms of treatment studied may not reflect dynamic therapy as it is typically practiced. Interpersonal therapy (34), for example, was investigated in four of the 1 1 studies, but this approach may be quite distant from the psychoanalytically oriented forms of dynamic therapy more commonly practiced. This aspect of the data base for this review further limits its generalizability.

rather

three

than

studies

examining

only

showed

considerable

symptomatic

positive

change.

All

evidence

for

the effectiveness of Sifneos’s approach. More research is needed to document the size of the effect on different forms of outcome. Another limitation of the studies I have reviewed is that many of the patient groups were types that clinicians believe are particularly difficult to treat. Included were two studies of opiate addicts (24, 30), one of co-

caine

abusers

(29),

and one of patients

with

personality

disorders (25). Although brief dynamic therapy may be most indicated for adjustment disorders, some anxiety disorders, and relationship conflicts, studies focusing on these problems have not been performed, with the exception of one study on posttraumatic stress disorder (27).

A

larger

effect

size

for

brief

dynamic

therapy

might be expected if these “ideal” patient types were chosen for research. The outcome measures of target symptoms, general symptoms (SCL-90), and social adjustment (Social Adjustment Scale) were selected because these measures are commonly used and it is preferable to calculate effect sizes within outcome domains rather than combining results across domains and measures. These measures, however, do not capture the specific areas where

short-term most

dynamic

successful.

therapy

Studies

measures-dynamic

theoretically

of more

conflicts,

should

theoretically

transference

be

relevant

themes,

and

relationship patterns (e.g., 47)-are beginning to appear, but these measures have not yet been used in efficacy studies. With the exception of Klerman’s interper-

sonal therapy, adjustment, the

which other

focuses on brief dynamic

manifest therapies

social were

An examination of what is not contained in this review can help further illuminate its limitations and point the way for future research. Lack of information on certain treatments, patient groups, outcome measures, various treatment lengths, follow-up assessments, and interaction hypotheses will be discussed in turn. Most notably missing from studies of brief dynamic

evaluated in terms of outcome measures that were not the central focus of treatment. Therapies such as medication, cognitive therapy, and behavioral treatments, which do focus directly on overt symptoms, might be expected to achieve larger changes on these measures. Larger effects for brief dynamic therapy may be evident once theoretically relevant measures are studied. Although previous research has often failed to detect specificity of the effects of different treatments in theo-

therapy

ap-

retically

important

proach (15). Although two studies comparing this approach to a waiting list control (44, 45) and a study involving Sifneos’s approach and two other brief dynamic therapies (46) have been conducted, data from these studies were not presented in a manner amenable to a meta-analysis. Means and standard deviations (or significance tests) were not presented for these studies, and the types of outcome measures used here were not employed. In addition, two studies (44, 45) used trainees as therapists. These studies, however, are important contributions to the literature on brief dynamic therapy. Unlike many of the studies used for the metaanalysis reported here, these three studies of Sifneos’s approach involved patients who were carefully selected on the basis of explicit criteria for short-term dynamic therapy. Also, the investigators in these studies attempted to operationalize psychodynamic change,

findings

is likely

What

156

Is Missing?

are

evaluations

of Sifneos’s

well-known

measuring

these

outcome to

that

the lack of the

changes in measures that for brief dynamic therapy,

patients

receive

an adequate

treatment. Howard et al. (48) pooled studies of eclectic therapy to determine

between outcome. achieve

“dose”

of such

difficulty

in

domains.

In searching for retically important

sential

domains,

be a function

of psychotherapy

are theoit is es-

“dose”

of

data from many the relationship

and

symptomatic

Their results indicated that 75% of patients an effective “dose” of therapy (i.e., symptom

relief) within 26 sessions. In psychodynamic important therapeutic work (the working process) is likely to take place after the initial

therapy, through symptom

relief, and an adequate period for such working through is probably necessary for dynamic change to occur. Thus, studies designed to test the efficacy of dynamic therapy should not only measure the theoretically im-

Am

/ Psychiatry

149:2,

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1992

PAUL

portant

variables

but should

also allow

enough

time for

change

in these variables to occur. It may not be necessary, of course, for the working through to occur only during psychotherapy sessions. A very brief (12-session) dynamic therapy might begin the working through, and then the successful patient

might

be able

to continue

the process

after

the termina-

tion of treatment (18). Research on this process would have to include assessment of therapeutic benefits some time after the treatment formally ends. As mentioned earlier, few follow-up results are available. Ideally, the follow-up period should be free of further treatment, since this additional treatment would confound inter-

pretation

of the benefits

apparent

at the follow-up

as-

sessment. No studies performed to date have attempted to control the follow-up period. With patients in need of further treatment, however, the ethical problems of withholding treatment would have to be considered. A final issue not taken up by this review is the role of other factors that might moderate the relationship between treatment type and outcome. Investigators would do well to look for interactions between patient characteristics and treatment types in evaluating efficacy data. The study by Piper et al. (22) on changes associated with dynamic therapy and a waiting list control condition for patients with high and low “quality of object relations” is an excellent example of the examination of interactions. To a certain extent this issue reduces to the problem discussed earlier, defining the appropriate patient group for dynamic therapy. It is unlikely, however, that only patients who seem theoretically suitable for dynamic therapy will be selected in future studies, especially considering the current diagnostic emphasis in psychiatry and the resulting constraints on federally funded research. Rather than select patients on the basis of suitability for dynamic therapy, researchers are more likely to measure variations in patient characteristics and relate these variables to outcome within and across treatment modalities. The construct of “suitability for dynamic therapy” itself needs further research. Although there are clinical indicators of this quality, no reliable and valid assessment device has yet been created that can be used to test these clinical hypotheses. Actually, it may be of interest to ask not only what types of patients are in general suitable for dynamic therapy but also what types of patients do best and worst in brief dynamic therapy com-

pared

to an alternative

therapy.

For example,

when

one

compares the process of dynamic therapy and cognitive therapy, a hypothesis that comes to mind is that patients who have more interest in examining the subtle, complex meanings of events and interpersonal transac-

tions

are a better

match

(and

therefore

would

have

bet-

ter outcomes) with dynamic therapy and that patients who are more task oriented and see things in a more cut-and-dried fashion would probably prefer a straightforward, logical therapy, such as cognitive therapy, which gives a clear, direct explanation of their problems and proceeds in steps with regular homework assignments. By asking these more and more refined ques-

Am

/ Psychiatry

149:2,

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1992

tions, researchers the conditions other therapies

CRITS-CHRISTOPH

stand a better chance under which dynamic are most effective.

of uncovering therapies and

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Pilkonis

PA,

Imber

SD,

Lewis

P, Rubinsky

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