Empirical Studies Bibliography

Title: The Psychotherapy Research Project of the Menninger Foundation: An Overview 
Author: Wallerstein, Robert S. 
Source: J Consult Clin Psychol. 1989 Apr;57(2):195-205.

Abstract: Studied processes and outcomes of psychoanalysis and psychoanalytic psychotherapy, both expressive and supportive. 42 Ss were followed via initial, termination, and follow-up studies over the entire natural course of treatment, with 100% follow-up 2-3 years post-termination. Some follow-ups extended over the 30-year life span of the study. Detailed case histories and life histories were obtained from all 42 Ss.Psychoanalyses achieved more limited outcomes than predicted; psychotherapies often achieved more than predicted. Supportive mechanisms infiltrated all therapies, psychoanalyses included, and accounted for more of the achieved outcomes (including structural changes) than anticipated. An expanded new categorization of supportive therapeutic mechanisms is proposed, along with an elaboration of expressive therapeutic mechanisms.



Title: Follow-up of Psychoanalysis Five to Ten Years after Termination: III. The Relation between the Resolution of the Transference and the Patient-Analyst Match 
Author: Kantrowitz, JudyKatz, Ann L.; and Paolitto, Frank 

Source: J Am Psychoanal Assoc. 1990;38(3):655-78
Abstract: As part of a long-term follow-up study of the outcome of psychoanalysis, we examined the relation between the extent of resolution of the transference at termination and the characteristics of the patient-analyst match. For twelve of the seventeen patients interviewed five to ten years after termination of psychoanalysis, the researchers found that the patient-analyst match played a role in the outcome of the analysis. Illustrations of the influence of the match in cases where the transference was resolved and those where it was not are presented.


Title: Studies on the Efficacy of Child Psychoanalysis
Author: Fonagy, Peter and Moran, George S.
Source: J Consult Clin Psychol. 1990 Dec;58(6):684-95
Abstract: This article summarizes three studies that evaluated the psychoanalytic psychotherapeutic treatment of diabetic children and adolescents with grossly abnormal blood glucose profiles necessitating repeated admissions to hospital. Study 1 used time series analysis to demonstrate that improvements in control were predicted by unconscious themes emerging in the analytic material. Study 2 compared the effect of psychotherapeutic treatment with that of minimal psychological intervention in 2well-matched groups (n = 11). Patients in the treatment group were offered psychoanalytic psychotherapy 3-4 times per week on the hospital ward. The intervention was highly effective in improving the diabetic control of the children, and this improvement was maintained at 1-yr follow-up. Study 3 used single-case experimental design to demonstrate the marked effect of psychotherapeutic help on growth in diabetic children with short stature.



Title: The Differential Effect of Psychotherapy and Psychoanalysis with Anaclitic and Introjective Patients: The Menninger Psychotherapy Research Project Revisited 
Author: Blatt, Sidney J. 

Source: J Am Psychoanal Assoc. 1992;40(3):691-724.
Abstract: Analyses of the data from the Menninger Psychotherapy Research Project (MPRP) have consistently indicated little difference in the therapeutic outcome between patients seen in psychoanalysis and those seen in psychotherapy. Reanalysis of the data from the MPRP, utilizing a distinction between two broad configurations of psychopathology (Blatt, 1974),(1990a), (Blatt and Shichman, 1983), however, indicates that patients whose pathology focuses primarily on disruptions of interpersonal relatedness and who use primarily avoidant defenses (anaclitic patients), and patients whose pathology focuses primarily on issues of self-definition, autonomy, and self-worth and who use primarily counteractive defenses (introjective patients)differ in their responsiveness to psychotherapy and psychoanalysis. Based on recently developed procedures for systematically evaluating the quality of object representation on the Rorschach, reanalysis of the Menninger data reveals that anaclitic patients have significantly greater positive change in psychotherapy, while introjective patients have significantly greater positive change in psychoanalysis. These statistically significant patient-by-treatment interactions are discussed in terms of their clinical implications as well as the importance of differentiating among types of patients in studies of therapeutic outcome and of therapeutic process.



Title: The Efficacy of Psychoanalysis for Children with Emotional Disorders 
Author: Target, M. and Fonagy, P.
Source: The Efficacy of Psychoanalysis for Children with Emotional Disorders 

Abstract: Objective: This is the second report from a chart review of 763 cases of child psychoanalysis and psychotherapy at the Anna Freud Centre.

METHOD: Three hundred fifty-two children and adolescents were identified who met DSM-III-R criteria for emotional disorders or who had sleep or somatoform symptoms with marked emotional disturbance. Two hundred fifty-four were treated in full psychoanalysis, the remainder one to three times per week, for an average of 2 years. Outcome was indicated by diagnostic change and by change in overall adaptation, measured by theChildren's Global Assessment Scale (CGAS).


RESULTS: Of those treated for at least 6 months, 72% showed reliable improvement in adaptation, 24% still had some diagnosis at termination, and 15% still had an emotional disorder. Simple phobias were most likely to remit, and depressed children were least likely to return to normal CGAS levels. Children younger than 11 years were considerably more likely to be well at the end of treatment. Intensive treatment generally led to greater improvements, independently of age and treatment length. Certain disorders, and more severe pathology, required intensive treatment; 50% of severe cases showed no improvement in psychotherapy. Thirty-one percent of variance in CGAS change could be predicted, and greater than 50% when diagnostic groupings were examined separately.


CONCLUSION: Despite methodological limitations, the study identifies predictors of improvement (e.g., younger age, phobic symptoms, intensity and length of treatment) and shows that severe or pervasive pathology requires intensive analytic help.



Title: Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder: A Randomized Controlled Trial
Author:Bateman, Anthony and Fonagy, Peter

Source: Am J Psychiatry. 1999 Oct;156(10):1563-9.
Abstract: OBJECTIVE: This study compared the effectiveness of psychoanalytically oriented partial hospitalization with standard psychiatric care for patients with borderline personality disorder.

METHOD:Thirty-eight patients with borderline personality disorder, diagnosed according to standardized criteria, were allocated either to a partially hospitalized group or to a standard psychiatric care (control) group in a randomized controlled design. Treatment, which included individual and group psychoanalytic psychotherapy, was for a maximum of 18 months. Outcome measures included the frequency of suicide attempts and acts of self-harm, the number and duration of inpatient admissions, the use of psychotropic medication, and self-report measures of depression, anxiety, general symptom distress, interpersonal function, and social adjustment. Data analysis used repeated measures analysis of covariance and nonparametric tests of trend. 

RESULTS: Patients who were partially hospitalized showed a statistically significant decrease on all measures in contrast to the control group, which showed limited change or deterioration over the same period. An improvement in depressive symptoms, a decrease in suicidal and self-mutilatory acts, reduced inpatient days, and better social and interpersonal function began at 6 months and continued until the end of treatment at 18 months. 

CONCLUSIONS: Psychoanalytically oriented partial hospitalization is superior to standard psychiatric care for patients with borderline personality disorder. Replication is needed with larger groups, but these results suggest that partial hospitalization may offer an alternative to inpatient treatment.



Title: Varieties of Long-Term Outcome among Patients in Psychoanalysis and Long-Term Psychotherapy: A Review of Findings in the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (Stoppp)
Author: Blomberg, Johan; Broberg, Jeanette; Carlsonn, Jan;Lazar, Anna; Sandell, Rolf; and Schubert, Johan 

Source: Int J Psychoanal. 2000 Oct; 81 ( Pt 5):921-42.

Abstract: This paper reports the main findings of a large-scale study of subsidized psychoanalysis and long-term psychotherapy. More than 400 people in various phases, before, during and after subsidized psychoanalysis or long-term psychodynamic psychotherapy, were followed up for a period of three years with personal interviews, questionnaires and official statistics. Our analyses revealed progressive improvement the longer patients were in treatment—impressively strong among patients in psychoanalysis—on self-rating measures of symptom distress and morale. Improvement, however, was equally weak in both groups on a self-rating measure of social relations. Dosage factors(treatment duration and session frequency in combination) partly accounted for the outcome differences between those referred to psychoanalysis and those referred to long-term psychotherapy. Attitudes and ideals among therapists and analysts concerning the goals and means of psychotherapy were also associated with patient outcome, although in rather complex ways. A significant part of the outcome differences between patients in psychoanalysis and in psychotherapy could be explained by the adoption, in a large group of therapists, of orthodox psychoanalytic attitudes that seemed to be counterproductive in the practice of psychotherapy but not in psychoanalysis. It is suggested that this effect may be a negative transfer of the psychoanalytic stance into psychotherapeutic practice and that this may be especially pronounced when the attitudes are not backed up by psychoanalytic training.



Title: The Cost-Effectiveness of Psychotherapy and Paroxetine for Severe Irritable Bowel Syndrome 
Author: Creed, F.; Fernandes, L.; Guthrie, E.;Palmer, S.; Ratcliffe, J.; Read, N.; et al.
Source: Gastroenterology, 124(2), 303-317, 2003

Abstract: BACKGROUND & AIMS: Psychotherapy and antidepressants are effective in patients with severe irritable bowel syndrome (IBS), but the cost-effectiveness of either treatment in routine practice has not been established.

METHODS: Patients with severe IBS were randomly allocated to receive 8 sessions of individual psychotherapy, 20 mg daily of the specific serotonin reuptake inhibitor (SSRI) antidepressant, paroxetine, or routine care by a gastroenterologist and general practitioner. Primary outcome measures of abdominal pain, health-related quality of life, and health care costs were determined after 3 months of treatment and 1 year later.


RESULTS: A total of 257 subjects (81% response rate) from 7 hospitals were recruited; 59 of 85 patients (69%) randomized to psychotherapy and 43 of 86 (50%) of the paroxetine group completed the full course of treatment. Both psychotherapy and paroxetine were superior to treatment as usual in improving the physical aspects of health-related quality of life (SF-36 physical component score improvement, 5.2 [SEM, 1.26], 5.8 [SEM, 1.0], and -0.3 [SEM, 1.17]; P < 0.001), but there was no difference in the psychological component. During the follow-up year, psychotherapy but not paroxetinewas associated with a significant reduction in health care costs compared with treatment as usual (psychotherapy, $976 [SD, $984]; paroxetine, $1252 [SD, $1616]; and treatment as usual, $1663 [SD, $3177]).


CONCLUSIONS: For patients with severe IBS, both psychotherapy and paroxetine improve health-related quality of life at no additional cost


Title: How to Study the ‘Quality of Psychoanalytic Treatments’ and Their Long-Term Effects on Patients' Well-Being: Representative,Multi-Perspective Follow-Up Study 
Author: Beutel, Manfred;Leuzinger-Bohleber, Marianne; Rüger, Bernhard; and Stuhrast, Ulrich

Source: Int J Psychoanal. 2003 Apr;84(Pt 2):263-90.
Abstract: How can we study the ‘quality of psychoanalytic treatments’? The authors attempt to answer this question by discussing a naturalistic, multi-perspective and representative follow-up study of psychoanalyses and long-term psychoanalytic psychotherapies. We studied a representative sample (n = 401) of all the patients who had terminated their psychoanalytic treatments with members of the German Psychoanalytical Association (DPV) between 1990 and 1993. Between 70 and 80 per cent of the patients achieved (average 6.5 years after the end of treatment) good and stable psychic changes according to the evaluations of the patients themselves, their analysts, independent psychoanalytic and non-psychoanalytic experts, and questionnaires commonly applied in psychotherapy research. The evaluation of mental health costs showed a cost reduction through fewer days of sick leave during the seven years following the end of long-term psychoanalytic treatments.The results achieved using non-psychoanalytical instruments are complemented by the richness of the idiosyncratic findings, gained by the psychoanalytic research instruments.



Title: The Personality Disorders Institute/Borderline Personality Disorder Research Foundation Randomized Control Trial for Borderline Personality Disorder: Rationale, Methods, and Patient Characteristics 
Author: Clarkin, John F.; Kernberg, Otto F.; Lenzenweger, Mark F.; and Raymond Levy, PsyD; Levy, Kenneth N. 

Source: J Pers Disord. 2004 Feb;18(1):52-72.
Abstract: The Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial (PDI/BPDRF RCT) is a controlled outcome study for borderline personality disorder (BPD) in which 90 participants were randomized to one of three manualized and monitored, active psychosocial treatment conditions. These treatments are: (a) Transference-Focused Psychotherapy (TFP; Clarkin, Yeomans, & Kernberg, 1999), a treatment for BPD based on object-relational and psychoanalytic principles first applied to BPD by Kernberg (1996), notable for its particular emphasis on interpretation of object relations activated in the ongoing therapeutic relationship; (b) Dialectical Behavior Therapy (DBT; Linehan, 1993), a popular treatment for BPD, with evidence of efficacy (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991)that emphasizes a balance between acceptance and change in its combination of cognitive-behavioral and Zen principles; and (c) supportive psychotherapy(Rockland, 1992), another object-relational and psychoanalytically basedtreatment for BPD which, in contrast to TFP, eschews transference interpretational places primary emphasis on development of a collaborative engagement with the patient to foster identity development. 

Patients received medication, if clearly indicated, according to the treatment algorithm developed by Soloff (2000). This article describes the significance and rationale of the study and the overall design, methods, plan of analysis, and demographic characteristics of the recruited sample of patients.



Title: A Randomized Trial of the Effect of Four Forms of Psychotherapy on Depressive and Anxiety Disorders
Author: Knekt, P. and Lindfors, O., eds.
Source: KELA. The Social Insurance Institution, Finland,  Studies in social security and health 77

Abstract: The Helsinki Psychotherapy Study (HPS) is a randomized clinical trial comparing the effectiveness of four forms of psychotherapy in the treatment of depressive and anxiety disorders. A total of 367 Finnish psychiatric outpatients from the Helsinki region, 20-46 years of age and suffering from depressive or anxiety disorders, were recruited fi the study on 1994-2000. A total of 326 patients were randomly assigned to one of 3 treatment groups: solution-focused therapy, short-term psychodynamic psychotherapy, and long-term psychodynamic psychotherapy. The patients assigned to the long-term psychodynamic psychotherapy group and 41 patients self-selected for psychoanalysis were included in a quasi-experimental design. The primary outcome measures were depressive and anxiety symptoms, while secondary measures included work ability, need for treatment, personality functions, social functioning, and life style. Cost-effectiveness was determined. The data were collected from interviews, questionnaires, psychological tests and public health registers. The outcome measures were assessed up to 9 times during a 5-year follow-up. Patients on short-term psychodynamic psychotherapy and solution-focused psychotherapy showed considerable decline in depressive and anxiety symptoms during the first year of follow-up, whereas work ability, personal functions and social functioning were only slightly improved. The result did not differ between the 2 forms of therapy; both types are thus effective in the treatment of depressive and anxiety disorders but for the majority of patients they are not sufficient in producing recovery, longer follow-ups are needed to evaluate the duration of treatment effects in the 2 groups. The HPS is one of the largest clinical trials on the effect of psychotherapy in the treatment of depressive and anxiety disorders. The results are likely to be incorporated into clinical practice and to impact public health.



Title: The Göttingen Study of Psychoanalytic Therapy: First Results 
Author: Biskup, Joachim; Kreische, Reinhard; Leichsenring, Falk; and Staats, Hermann 

Source: Int J Psychoanal. 2005 Apr;86(Pt 2):433-55.
Abstract: Results of a naturalistic study of the effectiveness of psychoanalytic therapy are reported. Outcome data are presented for a sample of N = 36 patients who were treated with psychoanalytic therapy. For a sample of n = 23 of these patients, data for1-year follow-up are available at present. According to the results, psychoanalytic therapy yielded significant improvements in symptoms (Symptom Checklist 90-R, SCL-90-R and rating of psychoanalysts), in interpersonal problems (Inventory of Interpersonal Problems, IIP), in quality of life(Questionnaire of Quality of Life, FLZ), in well-being (Questionnaire of Changes in Experience and Behaviour, VEV) and in target problems defined by the patients(Goal Attainment Scaling, GAS). Large effect sizes between 1.28 and 2.48 were found in symptoms (GSI of the SCL-90-R), interpersonal problems (IIP-total), quality of life (FLZ-total), well-being (VEV) and target problems (GAS). At1-year follow-up, all improvements proved to be stable or even increased. The self-reported improvements in symptoms were corroborated by the ratings of the psychoanalysts. At the end of therapy, 77% of the patients showed clinically significant improvements. In the 1-year follow-up group, this was true for 80%.Further results are presented and discussed.



Title: Manualized Supportive-Expressive Psychotherapy versus Non manualized Community-Delivered Psychodynamic Therapy for Patients with Personality Disorders: Bridging Efficacy and Effectiveness
Author: Barber, Jacques P.; Gallop, Robert; Norén, Kristina;Vinnars, Bo; and Weinryb, Robert M. 

Source: Am J Psychiatry. 2005 Oct;162(10):1933-40.
Abstract: OBJECTIVE: Time-limited manualized dynamic psychotherapy was compared with community-delivered psychodynamic therapy for outpatients with personality disorders.

METHOD: In a stratified randomized clinical trial, 156patients with any personality disorder diagnosis were randomly assigned either to 40 sessions of supportive-expressive psychotherapy (N=80) or to community-delivered psychodynamic therapy (N=76). Assessments were made at intake and 1 and 2 years after intake. Patients were recruited consecutively from two community mental health centers (CMHCs), assessed with the Structural Clinical Interview for DSM-IV Axis II Personality Disorders, and included if they had a diagnosis of any DSM-IV personality disorder. The outcome measures included the presence of a personality disorder diagnosis, personality disorder severity index, level of psychiatric symptoms (SCL-90), Global Assessment of Functioning Scale score, and number of therapy sessions. General mixed-model analysis of variance was used to assess group and time effects. 

RESULTS:In both treatment conditions, the global level of functioning improved while there were decreases in the prevalence of patients fulfilling criteria for a personality disorder diagnosis, personality disorder severity, and psychiatric symptoms. There was no difference in effect between treatments. During the follow-up period, patients who received supportive-expressive psychotherapy made significantly fewer visits to the CMHCs than the patients who received community-delivered psychodynamic therapy. 

CONCLUSIONS: Manualized supportive-expressive psychotherapy was as effective as non manualized community-delivered psychodynamic therapy conducted by experienced dynamic clinicians.




Title: Assessing Personality Change in Psychotherapy with the SWAP–200: A Case Study
Author: Gazzillo, Francesco; Lingiardi, Vittorio; and Shedler, Jonathan 

Source: J Pers Assess. 2006 Feb;86(1):23-32.
Abstract: Many studies document the efficacy of psychotherapy for acute syndromes such as depression, but less is known about personality change in patients treated for personality pathology. The Shedler–Westen Assessment Procedure (SWAP–200; Westen & Shedler, 1999a, 1999b) is an assessment tool that measures a broad spectrum of personality constructs and is designed to bridge the gap between the clinical and empirical traditions in personality assessment. In this article, we demonstrate the use of the SWAP–200 as a measure of change in a case study of a patient diagnosed with borderline personality disorder. We collected assessment data at the start of treatment and after 2 years of psychotherapy. The findings illustrate the personality processes targeted in intensive psychotherapy for borderline personality.



Title: A Programmatic Study of Short-Term Psychodynamic Psychotherapy: Assessment, Process, Outcome, and Training 
Author: Hilsenroth, Mark J.

Source: Psychotherapy Research 01/2007; 17(1):31-45. 
Abstract: The author reviews findings from his research program on short-term psychodynamic psychotherapy. A hybrid model of psychotherapy research is outlined that integrates efficacy and effectiveness methodology to examine interrelated issues regarding: (a) psychological assessment, (b) psychotherapy process, (c) treatment outcome, and (d) training of graduate clinicians. The integration of applied clinical research initiatives into a doctoral training program, clinical implications, and directions for future research are also presented.



Title: Change in Attachment Patterns and Reflective Function in a Randomized Controlled Trial of Transference Focused Psychotherapy for Borderline Personality Disorder 
Author: Clarkin, J. F.; Kelly, K. M.; Kernberg, O. F.Levy, K. N.; Meehan, K. B.; Reynoso, J. S.; and Weber, M.
Source: Journal of Consulting and Clinical Psychology, 74(6):1027-1040.

Abstract: Changes in attachment organization and reflective function (RF) were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder (BPD). Ninety patients reliably diagnosed with BPD were randomized to transference-focused psychotherapy (TFP), dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. Attachment organization was assessed with the Adult Attachment Interview and the RF coding scale. After 12 months of treatment, participants showed a significant increase in the number classified secure with respect to attachment state of mind for TFP but not for the other 2 treatments. Significant changes in narrative coherence and RF were found as a function of treatment, with TFP showing increases in both constructs during treatment. No changes in resolution of loss or trauma were observed across treatments. Findings suggest that 1 year of intensive TFP can increase patients’ narrative coherence and RF. Future research should establish the relationship between these 2 constructs and relevant psychopathology, identify treatment component



Title: A randomized controlled clinical trial of pychoanalytic psychotherapy for panic disorder.
Author: Busch, F.; Clarkin, J.; Leon, A. C.; Milrod, B.; Rudden, M.; Schwalberg, M.; et al.
Source: American Journal of Psychiatry, 164 (2):265-272.

Abstract: OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Des- pite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors’ knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder.


METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18–55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure.

RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results.

CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.



Title: Short-Term Dynamically Oriented Psychotherapy: A Review and Meta-Analysis 
Author: Anderson, Edward M. and Lambert, Michael J. 

Source: Clinical Psychology Review Volume 15, Issue 6, 1995, Pages 503–514

Abstract: Twenty-six studies of the effectiveness of short-term dynamic therapy (STDT) were subjected to two meta-analyses. Effect sizes (ES) obtained by each method were similar. STDT attained average ESs of 71 and 34, relative to wait list and minimal treatment groups, respectively. When studies using psychosomatic patients were excluded, STDT achieved an ES of 85, relative to wait list groups. We found no evidence that STDT is superior or inferior to other forms of psychotherapy at post-treatment, although it evidenced a slight superiority at long-term follow-up assessment. There was, in addition, evidence that studies employing manuals or therapists trained in STDT produced larger ESs than those that did not.



Title: Does Psychoanalysis Work?
Author: Bachrach, H.; Galatzer-Levy, R.M.Skolnikoff, A.; and Waldron, Jr., S. 
Source: New Haven, Yale University Press, 2000

Abstract: A thorough survey of every major study of the efficacy of psychoanalytic treatment. The authors -- all well-known psychoanalysts -- critically analyze the studies and their findings, discuss the issues that have been and should be explored in such studies, and examine the problems in conducting research into psychoanalytic outcomes.

The authors begin by providing a definition of psychoanalysis, establishing central psychoanalytic goals, and determining what questions need to be addressed in assessing whether analysis is effective. They then describe their methods and criteria for evaluating modern research on psychoanalytic outcome and apply these criteria to four major studies of adult psychoanalytic patients, several studies of child and adolescent analysis, and some small-group studies. They find that all the studies show that psychoanalysis is an effective treatment for many patients -- and that some cherished assumptions about psychoanalysis are probably wrong. In the final part of the book, the authors address the challenges of collecting empirical data on psychoanalysis and explore the possibilities inherent in the single-case study.



Title: An Open Door Review of Outcome Studies in Psychoanalysis (Second Edition) 
Author: Allison,E.; Clarkin, J.; Fonagy, P.; Gerber, A.; Jones, E.E.; Kächele, H.; Krause, R.; and Perron, R.
Source: London, International Psychoanalytic Association, 2001(download or order via http://eseries.ipa.org.uk/prev/research/R-outcome.htm)



Title: Comparative Effects of Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy in Depression: A Meta-Analytic Approach 
Author: Leichsenring, Falk 

Source: Clin Psychol Rev. 2001 Apr;21(3):401-19.
Abstract: This article reviews the efficacy of short-term psychodynamic psychotherapy (STPP) in depression compared to cognitive-behavioral therapy (CBT) or behavioral therapy (BT). In this review, only studies in which at least 13 therapy sessions were performed have been included, and a sufficient number of patients per group were treated (N ? 20).With regard to outcome criteria, the results were reviewed for improvements in depressive symptoms, general psychiatric symptoms, and social functioning. Six studies met the inclusion criteria. Results: In 58 of the 60 comparisons (97%)performed in the six studies and their follow-ups, no significant difference could be detected between STPP and CBT/BT concerning the effects in depressive symptoms, general psychiatric symptomatology, and social functioning.Furthermore, STPP and CBT/BT did not differ significantly with regard to the patients that were judged as remitted or improved. According to a meta-analytic procedure described by R. Resentful (1991) the studies do not differ significantly with regard to the patients that were judged as remitted or improved after treatment with STPP or CBT/BT. The mean difference between STPP and CBT/BT concerning the number of patients that were judged as remitted or improved corresponds to a small effect size (post-assessment: ? = 0.08,follow-up assessment: ? = 0.12). Thus, STPP and CBT/BT seem to be equally effective methods in the treatment of depression. However, because of the small number of studies which met the inclusion criteria, this result can only be preliminary. Furthermore, it applies only to the specific forms of STPP that were examined in the selected studies and cannot be generalized to other forms of STPP. Further studies are needed to examine the effects of specific forms of STPP in both controlled and naturalistic settings. Furthermore, there are findings indicating that 16–20 sessions of both STPP and CBT/BT are insufficient for most patients to achieve lasting remission. Future studies should address the effects of longer treatments of depression.



Title: The Benefits of Individual Psychotherapy for People Diagnosed with Schizophrenia: A Meta-Analytic Review
Author: Gottdiener, W. H. and Haslam, N. 
Source: Ethical Human Sciences and Services, 4, 163-187. 2002

Abstract: A comprehensive meta-analytic review was undertaken to determine the efficacy of individual psychotherapy for people diagnosed with schizophrenia. Mean effect sizes were calculated for 37 studies conducted on 2642 patients. Possible moderator variables included (1) randomization, (2) source of data (between-groups and within-groups), (3) type of individual psychotherapy, (4) use of conjoint antipsychotic medication, (5) chronicity of the disorder, (6) treatment context, and (7) diagnostic criteria. Psychodynamic, cognitive-behavioral, and non-psychodynamic supportive therapies were all associated with improvement in functioning. Similar effect sizes were found between individual psychotherapy combined with antipsychotic medication and individual psychotherapy used without medication, for chronic schizophrenia compared with acute schizophrenia, and between studies that used randomization and those that did not. Larger effects existed for within-groups data compared with between-groups data, for outpatients compared with inpatients, and for studies conducted after the publication of DSM-III. Limitations of this review and suggestions for future research are discussed.



Title: The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders: A Meta-Analysis 
Author: Leichsenring, Falk and Leibing, Eric

Source: American Journal of Psychiatry, 160:1223–1232, 2003
Abstract: OBJECTIVE: The authors conducted a meta-analysis to address the effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders.

METHOD: studies of psychodynamic therapy and cognitive behavior therapy that were published between 1974 and 2001 were collected. Only studies that 1)used standardized methods to diagnose personality disorders, 2) applied reliable and valid instruments for the assessment of outcome, and 3) reported data that allowed calculation of within-group effect sizes or assessment of personality disorder recovery rates were included. Fourteen studies of psychodynamic therapy and 11 studies of cognitive behavior therapy were included. 

RESULTS:Psychodynamic therapy yielded a large overall effect size (1.46), with effect sizes of 1.08 found for self-report measures and 1.79 for observer-rated measures. For cognitive behavior therapy, the corresponding values were 1.00,1.20, and 0.87. For more specific measures of personality disorder pathology, a large overall effect size (1.56) was seen for psychodynamic therapy. Two cognitive behavior therapy studies reported significant effects for more specific measures of personality disorder pathology. For psychodynamic therapy,the effect sizes indicate long-term rather than short-term change in personality disorders. 

CONCLUSIONS: There is evidence that both psychodynamic therapy and cognitive behavior therapy are effective treatments of personality disorders. Since the number of studies that could be included in this meta-analysis was limited, the conclusions that can be drawn are only preliminary. Further studies are necessary that examine specific forms of psychotherapy for specific types of personality disorders and that use measures of core psychopathology. Both longer treatments and follow-up studies should be included.



Title: The Efficacy of Short-term Psychodynamic Psychotherapy in Specific Psychiatric Disorders: A Meta-Analysis
Author: Leibing, Eric; Leichsenring, Falk; and Sven Rabung 

Source: Arch Gen Psychiatry. 2004 Dec;61(12):1208-16.
Abstract: BACKGROUND: The efficacy of psychodynamic therapy is controversial. Previous meta-analyses have reported discrepant results. 

OBJECTIVE: To test the efficacy of short-term psychodynamic psychotherapy (STPP) in specific psychiatric disorders by performing a meta-analysis of more recent studies. We assessed outcomes in target problems, general psychiatric symptoms, and social functioning.

DESIGN: We identified studies of STPP published between January 1, 1970,and September 30, 2004, by means of a computerized search using MEDLINE,PsycINFO, and Current Contents. Rigorous inclusion criteria, included randomized controlled trials, use of treatment manuals and insurance of treatment integrity, therapists experienced or specifically trained in STPP, treatment of patients with specific psychiatric disorders, reliable and valid diagnostic measures, and data necessary to calculate effect sizes. Studies of interpersonal therapy were excluded. Seventeen studies fulfilled the inclusion criteria. The information was extracted by 3 raters. Effect sizes were calculated for target problems, general psychiatric symptoms, and social functioning using the data published in the original studies. To examine the stability of outcome, we assessed effect sizes separately for end of therapy and follow-up assessment. The effect sizes of STPP were compared with those of waiting-list control patients, treatments as usual, and other forms of psychotherapy.

RESULTS: Short-term psychodynamic psychotherapy yielded significant and large pretreatment-post treatment effect sizes for target problems (1.39),general psychiatric symptoms (0.90), and social functioning (0.80). These effect sizes were stable and tended to increase at follow-up (1.57, 0.95, and 1.19,respectively). The effect sizes of STPP significantly exceeded those of waiting-list controls and treatments as usual. No differences were found between STPP and other forms of psychotherapy.


CONCLUSIONS: Short-term psychodynamic psychotherapy proved to be an effective treatment in psychiatric disorders.However, further research of STPP in specific psychiatric disorders is needed,including a study of the active ingredients of STPP. Effectiveness studies should be included.



Title: Psychodynamic Psychotherapies: Evidence-Based Practice and Clinical Wisdom

Author: Fonagy, Peter; Higgitt, Anna; and Roth, Anthony

Source: Bulletin of the Menninger Clinic, 69(1):1-58, 2005
Abstract: This article is based on an exhaustive review of the psychotherapy outcomes literature, undertaken originally at the instigation of the UK Department of Health by Roth and Fonagy (Department of Health, 1995). We have recently updated this review (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Roth & Fonagy, 2004) and extended it to identify all studies of psychoanalytic psychotherapy. The usual methods for identifying studies were employed (Fonagy, Target, et al., 2002; Roth & Fonagy, in press). The key questions that should be asked of this literature given the current state of research in this area (also see Westen, Morrison, & Thompson–Brenner, 2004) are:


Are there any disorders for which short–term psychodynamic psychotherapy (STPP) can be considered evidence–based?

Are there any disorders for which STPP is uniquely effective as either the only evidence-based treatment or as a treatment that is more effective than alternatives?

Is there any evidence base for long–term psychodynamic psychotherapy (LTPP) either in terms of achieving effects not normally associated with short–term treatment or addressing problems that have not been addressed by STPP?


In this context, short–term therapy is conceived of as a treatment of around 20 sessions delivered usually once weekly.



Title: Short-Term Psychodynamic Psychotherapies for Common Mental Disorders 
Author: Abbass, A.A.; Hancock, J.T.;Henderson, J; and Kisely S. 
Source: Cochrane Database of Systematic Reviews, (4):CD004687, 2006

Abstract: BACKGROUND: Over the past 40 years, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders have been developed and studied. Four published meta-analyses of STPP, using different methods and samples, have found conflicting results. 

OBJECTIVES: This review evaluated the efficacy of STPP relative to minimal treatment and non-treatment controls for adults with common mental disorders.

SEARCH STRATEGY: We searched CCDANCTR-Studies and CCDANCTR-References on 25/4/2005, CENTRAL, MEDLINE, CINAHL, EMBASE, PsycINFO, DARE and Biological Abstracts were also searched. We contacted triallists and checked references from papers retrieved.

SELECTION CRITERIA: All randomised controlled trials (RCT) of adults with common mental disorders, in which a brief psychodynamic therapy lasting less than 40 hours in total, and provided in individual format, were included.

DATA COLLECTION AND ANALYSIS: Three reviewers working in pairs evaluated studies. Studies were selected only if pairs of reviewers agreed they met inclusion criteria. A third reviewer was consulted if two reviewers could not reach consensus. Data were collected and entered into Review Manager. Study quality was assessed and scored by pairs of raters. Publication bias was assessed using a funnel plot. Sensitivity analyses were also conducted.

MAIN RESULTS: 23 studies of 1431 randomised patients with common mental disorders were included. These studies evaluated STPP for general, somatic, anxiety, and depressive symptom reduction, as well as social adjustment. Outcomes for most categories of disorder suggested significantly greater improvement in the treatment versus the control groups, which were generally maintained in medium and long term follow-up. However, only a small number of studies contributed data for each category of disorder, there was significant heterogeneity between studies, and results were not always maintained in sensitivity analyses.

AUTHORS' CONCLUSIONS: STPP shows promise, with modest to moderate, often sustained gains for a variety of patients. However, given the limited data and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.



Title: The Place of Psychoanalytic Treatments within Psychiatry
Fonagy, Peter; Gabbard, Glen O.; and Gunderson, John G.

Source: Archives of General Psychiatry, 59(6):505-510, 2002
Abstract: Psychoanalytic treatments may be necessary when other treatments are ineffective. An empirically grounded framework for the use of these treatments involves sources of evidence from both efficacy and effectiveness studies. Preliminary evidence suggests that psychoanalysis appears to be consistently helpful to patients with milder disorders and somewhat helpful to those with more severe disturbances. A greater number of controlled studies are necessary to confirm these impressions. A multi-site process and outcome study is proposed.



Title: The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials
Author: Westen, Drew; Novotny, Catherine M.; and Thompson-Brenner, Heather
Source: Psychological Bulletin, 130(4):631-663, 2004
Abstract: This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies(ESTs) imposes particular assumptions on the use of randomized controlled trial(RCT) methodology that appear to be valid for some disorders and treatments(notably exposure-based treatments of specific anxiety symptoms) but substantially violated for others. Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported. The authors recommend changes in reporting practices to maximize the clinical utility of RCTs, describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated, and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies.



Title: When Clinical Description Becomes Statistical Prediction
Author: Westen, Drew and Weinberger, Joel 
Source: American Psychologist, 59(7):595-613, 2004
Abstract: This article reconsiders the issue of clinical versus statistical prediction. The term clinical is widely used to denote 1 pole of 2 independent axes: the observer whose data are being aggregated (clinician/expert vs. lay) and the method of aggregating those data(impressionistic vs. statistical). Fifty years of research suggests that when formulas are available, statistical aggregation outperforms informal, subjective aggregation much of the time. However, these data have little bearing on the question of whether, or under what conditions, clinicians can make reliable and valid observations and inferences at a level of generality relevant to practice or useful as data to be aggregated statistically. An emerging body of research suggests that clinical observations, just like lay observations, can be quantified using standard psychometric procedures, so that clinical description becomes statistical prediction. 



Title: The Characteristics, Identification, and Applications of Frames 
Author: Dail, Hurtful and Teller, Virginia

Source: Psychotherapy Research, 4(3&4):253-276, 1994
Abstract: FRAMES (Fundamental Repetitive and Maladaptive Emotion Structures) provide a multipurpose research tool for assessing psychopathology, the psychotherapeutic process and, finally, the treatment outcome. We outline the clinical and theoretical assumptions that underlie and motivate FRAMES, along with the aims of an ongoing research program. We describe four methods for identifying FRAMES, ranging from our original justified intuition (Method A) to the present systematic set of reliable procedures (Method D). The reliability of necessary judgments, the validity of findings and the strengths and weaknesses are discussed. The FRAMES approach has been successfully used to analyze verbatim transcripts of recorded psychoanalytic and psychotherapy sessions and videotapes and coded records of the behavior of three-year-old children. By applying the FRAMES method to an initial evaluation interview, we demonstrate its usefulness on quite different clinical material.



Title: Conscious and Unconscious Processes: Psychodynamic, Cognitive, and Neurophysiological Convergences 
Author: Bond, J. A.; Brakel, L. A. W.Hertel, R.K.; Shevrin, H.; and Williams, W. J. 
Source: New York, Guilford Press,1996

Abstract: The notion of an unconscious mental life has been subject to debate for over a century. Psychodynamic practitioners generally understand clients' consciously experienced symptoms to reflect conflict within an unconscious realm; cognitive psychologists, on the other hand, doubt the validity of this psychodynamic understanding of unconscious processes. This volume attempts to bridge the theoretical gulf between the two approaches by providing objective evidence for unconscious conflict in psychopathology. Integrating psychodynamic, cognitive, and neurophysiological methods, the authors have developed an experimental model using brain wave measurements that can differentiate types of unconscious processes. The volume provides a unique synthesis of clinical and experimental findings and blazes a new pathway for the study of brain mind interaction.



Title: Psychoanalysis and Cognitive Science: A Multiple Code Theory 
Author: Bucci, W.
Source: New York, Guilford, 1997

Abstract: Although psychoanalytic concepts underlie most forms of psychotherapy practiced today, the basic Freudian theory of mind the metapsychology does not mesh with current scientific views in psychology and related fields. As a result, despite its many strengths, psychoanalysis has been relegated to the periphery by clinicians and researchers alike. Filling a significant void, this book from cognitive scientist and psychoanalytic researcher Wilma Bucci proposes a new model of psychological organization that integrates psychoanalytic theory with the investigation of mental processes. Solidly rooted in current cognitive science, multiple code theory recognizes the focus on meanings and motives that is intrinsic to psychoanalytic clinical work. The theory points to parallel functions underlying free association and dreams, as well as conceptual development in children and creative work in sciences and the arts, and provides a strong foundation for empirical research on the psychoanalytic treatment process.



Title: How Expert Clinicians’ Prototypes of an Ideal Treatment Correlate with Outcome in Psychodynamic and Cognitive-Behavioral Therapy 
Author: Ablon, J.S. and Jones, E.E.

Source: Psychotherapy Research, Vol 8(1), 1998, 71-83.
Abstract: An innovative methodology is presented for identifying and assessing change process in psychoanalytic treatments. Using the Psychotherapy Process Q-set (PQS), a panel of experienced psychoanalysts developed a prototype of an ideal psychoanalytic hour. This prototype was then applied to verbatim transcripts of three archived treatment samples: psychoanalyses, long-term analytic therapies, and brief psycho dynamic therapies. The degree to which these treatments fostered an analytic process as represented by the prototype was measured quantitatively. Analytic process was significantly more present in psychoanalyses than in the long-term analytic therapies, which, in turn fostered significantly more analytic process than did brief psychodynamic therapies. The study demonstrates that, given descriptive language that does not represent a particular theoretical perspective, analysts can agree on a definition of analytic process, and that analytic process can be operationalized and quantitatively assessed. A second study demonstrates that despite consensus on its definition, there is not just one proper analytic process; rather, there are change processes unique to each dyad. Two quantitative case studies illustrate how each analytic pair has a unique interaction pattern linked to treatment progress. These dyad-unique "interaction structures" are recurrent, mutually influencing patterns of interaction, the experience, recognition, and comprehension of which appear to be a fundamental component of therapeutic action. A bi-personal model is described that attempts to bridge theories of therapeutic action that focus on insight and self-understanding and those that emphasize the patient's experience of the therapist.



Title: Understanding Transference: The Core Conflictual Relationship Theme Method (Second Edition)
Author: Luborsky, L. and Crits-Christoph, P.
Source: Washington, D.C., American Psychological Association, 1998

Abstract: In the first volume of "Understanding Transference: The CCRT Method", Luborsky and Christoph provided concrete validation of Freud's observations about transference. Using Lester Luborsky's "core conflictual relationship theme" (CCRT) method, they demonstrated how to reliably measure recurring patterns in patients' central relationships and how to explore such patterns within both psychodynamic and other types of therapies. This edition seeks to show why the CCRT method is a good empirical measure of transference and why it continues to be used by researchers and clinicians. All chapters in the second edition have been revised and updated, and six are new. Part I surveys the basics of the CCRT method and provides detailed illustration of the CCRT scoring of patient narratives. The Relationship Anecdotes Paradigm, a versatile method for obtaining narratives, is described in Chapter 7. The book delves deeper into the multiple facets of the CCRT in Part II, where it explores nine directions to find the meaning of the CCRT measure. There is also an expanded study of the CCRT within narratives and dreams. In Part III, the book turns to clinical applications of the CCRT method, including everyday uses of the CCRT in practice. Finally, the book ends with an integrative summary reflecting on the convergence of many CCRT findings with Freud's observations about transference.



Title: The Effectiveness of Psychoanalytic Psychotherapy: The Role of Treatment Duration, Frequency of Sessions, and the Therapeutic Relationship 
Author: Freedman, N.; Frosch, A.;Hoffenberg, J.D.; and Vorus, N. 
Source: J Am Psychoanal Assoc. 1999;47(3):741-72.

Abstract: This is an effectiveness study of treatment outcome that relies on patients' perception of their mental health during and after psychoanalytic psychotherapy. Ninety-nine outpatients attending the IPTAR Clinical Center (ICC) responded to the Effectiveness Questionnaire (EQ) adapted from that developed by Consumer Reports. Effectiveness is studied from various perspectives. Findings indicated (1) an incremental gain in effectiveness scores from six to over twenty-four months of therapy; (2) an incremental gain with greater session frequency from one to two or three weekly sessions; (3) facilitation of effectiveness by the experience of a positive relationship with the therapist; (4) an interplay between clinical syndrome and treatment conditions. A method giving clinical validity to the quantitative findings is described. Brief summaries of two recorded interviews reveal differential reconstruction of events that had occurred during treatment. The findings are discussed from the vantage point of two hypotheses: cognitive dissonance and internalization of therapeutic experience.



Title: Alliance Predicts Patients' Outcome beyond In-Treatment Change in Symptoms 
Author: Barber, Jacques P.; Connolly, Mary Beth; Crits-Christoph, Paul; Gladis, Lynn; and Siqueland, Lynne 
Source: Journal of Consulting and Clinical Psycholology, 68(6):1027-1032, 2000

Abstract: The authors examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvement in a group of 86 patients with generalized anxiety disorders, chronic depression, or avoidant or obsessive-compulsive personality disorder who received supportive-expressive dynamic psychotherapy. Although alliance at Sessions 5 and 10, but not at Session 2, was associated with prior change in depression, alliance at all sessions significantly predicted subsequent change in depression when prior change in depression was partialed out. The results are discussed in terms of the causal role of the alliance in therapeutic outcome.


Title: Psychoanalysis - With Whom, For What,and How? Comparisons with Psychotherapy 
Author: Blatt, S.J.and Shahar, G.

Source: J Am Psychoanal Assoc. 52(2):393-447, 2004
Abstract: If psychoanalytic treatment is to survive in the era of evidence-based medicine and managed care systems,empirical evidence is needed to demonstrate its unique nature and effectiveness.To address this need, comprehensive analyses were conducted of data from the Menninger Psychotherapy Research Project (Wallerstein 1986). These analyses addressed three questions:


What are the differences in outcome between psychoanalysis (PSA) and supportive-expressive psychotherapy (SEP)?

With what types of patient, and in what ways, are these two psychodynamic treatments differentially effective?

Are these differences in outcome the consequence of possibly different mechanisms of therapeutic action?


PSA was found to contribute significantly to the development of adaptive interpersonal capacities and to the reduction of maladaptive interpersonal tendencies, especially with more ruminative, self-reflective, introjective patients, possibly by extending their associative capacities. SEP, by contrast, was effective only in reducin g maladaptive interpersonal tendencies and only with dependent, unreflective, more affectively labile anaclitic patients, possibly by containing or limiting their associative capacities.



Title: On Analytic Process 
Author: Ablon, J.S. and Jones, E.E.
Source: J Am Psychoanal Assoc 53(2):541-568, 2005

Abstract: An innovative methodology is presented for identifying and assessing change process in psychoanalytic treatments. Using the Psychotherapy Process Q-set (PQS), a panel of experienced psychoanalysts developed a prototype of an ideal psychoanalytic hour. This prototype was then applied to verbatim transcripts of three archived treatment samples: psychoanalyses, long-term analytic therapies, and brief psychodynamic therapies. The degree to which these treatments fostered an analytic process as represented by the prototype was measured quantitatively. Analytic process was significantly more present in psychoanalyses than in the long-term analytic therapies, which, in turn fostered significantly more analytic process than did brief psychodynamic therapies. The study demonstrates that, given descriptive language that does not represent a particular theoretical perspective, analysts can agree on a definition of analytic process, and that analytic process can be operationalized and quantitatively assessed. A second study demonstrates that despite consensus on its definition, there is not just one proper analytic process; rather, there are change processes unique to each dyad. Two quantitative case studies illustrate how each analytic pair has a unique interaction pattern linked to treatment progress. These dyad-unique "interaction structures" are recurrent, mutually influencing patterns of interaction, the experience, recognition, and comprehension of which appear to be a fundamental component of therapeutic action. A bipersonal model is described that attempts to bridge theories of therapeutic action that focus on insight and self-understanding and those that emphasize the patient's experience of the therapist.



Title: Analysis of the Patient-Therapist Relationship in Dynamic Psychotherapy: An Experimental Study of Transference Interpretations 
Author: Svein, Amlo; Bøgwald,Kjell-Petter; Heyerdahl, Oscar; Høglend, Per; Marble, Alice; Sjaastad, MaryCosgrove; and Sørbye, Øystein

Source: American Journal of Psychiatry, 163:1739-1746, 2006
Abstract: OBJECTIVE: The purpose of this study was to measure the effects of transference interpretations (the assumed core active ingredient) in dynamic psychotherapy, using an experimental design. 

METHOD: One hundred patients were randomly assigned to two groups. One group received dynamic psychotherapy over 1 year, with a moderate level of transference interpretations, while the other group received dynamic psychotherapy with no transference interpretations. The most common axis I disorders were depression and anxiety disorders. Forts patients fulfilled the general criteria for personality disorder. Seven experienced psychotherapists treated patients in both groups. Five full sessions from each treatment were rated by two evaluators with process measures in order to document treatment integrity. Outcome variables were the Psychodynamic Functioning Scales, Inventory of Interpersonal Problems Scale-Circumplex version, Global Assessment of Functioning Scale, and Symptom Checklist-90-R.Quality of Object Relations Scale (lifelong pattern) and personality disorders were preselected as possible moderators of treatment effects. Change was assessed using linear-mixed models. Clinically significant change was also calculated. 

RESULTS: The authors could not demonstrate differential treatment effects between the groups. However, the moderator analyses showed that transference interpretations were more helpful for patients with a lifelong history of less mature object relations. Small negative effects were observed for patients with mature object relations. CONCLUSIONS: The authors could not show differences in average effectiveness between treatments. However, the moderator analyses indicated that treatment worked through different active ingredients for different patients. Contrary to common expectation, patients with poor object relations profited more from therapy with transference interpretations than from therapy with no transference interpretations.



Title: Relation of the Therapeutic Alliance with Outcome and Other Variables: A Meta-Analytic Review
Author: Davis, M. Katherine; Garske, John P.; and Martin, Daniel J. 
Source: Journal of Consulting and Clinical Psychology, 68(3):438-450, 2000

To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of out comemeasure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study. 



Title: A Review of Therapist Characteristics and Techniques Positively Impacting the Therapeutic Alliance
Author: Ackerman, S.J. and Hilsenroth, M.J.
Source: Clinical Psychology Review, 23(1):1-33, 2003

The present review is a comprehensive examination of the therapist's personal attributes and in-session activities that positively influence the therapeutic alliance from a broad range of psychotherapy perspectives. Therapist's personal attributes such as being flexible, honest, respectful, trustworthy, confident, warm, interested, and open were found to contribute positively to the alliance. Therapist techniques such as exploration, reflection, noting past therapy success, accurate interpretation, facilitating the expression of affect, and attending to the patient's experience were also found to contribute positively to the alliance. This review reveals how these therapist personal qualities and techniques have a positive influence on the identification or repair of ruptures in the alliance.



Title: The Psychological Unconscious: A Necessary Assumption for All Psychological Theory? 
Author: Dickman, S.and Shevrin, H. 
Source: American Psychologist, 35, 421-434,1980



Title: Mommy and I Are One: Implications for Psychotherapy 
Author: Silverman, Lloyd H. and Weinberger, Joel
Source: The American Psychologist, 40(12):1296-1308, 1985
Presents evidence to support the thesis that there are powerful unconscious wishes for a state of oneness with "the good mother of early childhood" and that gratification of these wishes can enhance adaptation. Data come from experiments that used the subliminal psychodynamic activation method with over 40 groups of Ss from varied populations, including schizophrenics, neurotics, and normal students. These studies have reported that the 4-msec exposure of stimuli intended to activate unconscious symbiotic like fantasies (usually the words “Mommy and I are one”) produced ameliorative effects on different dependent variables in a variety of settings. It is proposed that patient-therapist relationship factors in psychotherapy, seen by many as a common agent of change in different forms of treatment, owe their effectiveness partly to their having activated these symbiotic like fantasies.Further studies are outlined that would provide a more definitive test of this proposition. (107 ref)



Title: Transference in Interpersonal Relations: Inferences and Affect Based On Significant-Other Representations 
Author: Andersen, S.M. and Baum, A.

Source: Journal of Personality, 62(4):459-497, 1994
Based on an information-processing model of transference and a recent experimental demonstration of transference, defined in terms of "biased inference and memory" (Andersen & Cole, 1990), the present research examined the transfer of affective responses to a new individual, as in schema-triggered affect (Fiske, 1982). Using idiographic stimulus-generation procedures and a nomothetic experimental design, we exposed subjects to a description of a new, unknown person, allegedly seated next door. The description resembled either a positively or negatively toned significant other from the subject's own life or from another subject's life. As predicted and replicating previous work, subjects mis remembered the target person as having more representation-consistent features when the target resembled their own significant other rather than someone else's. Moreover, and also as predicted,subjects transferred more representation-consistent affect to this same target person. The data are discussed in terms of conceptions of transference and basic aspects of social cognition.



Title: The Relation of Attachment Status, Psychiatric Classification, and Response to Psychotherapy 
Author: Fonagy, Peter; Gerber, Andrew; Kennedy, Roger; Leigh,Tom; Mattoon, Gretta; Steele, Howard; Steele, Miriam; and Target, Mary
Source: Journal of Consulting and Clinical Psychology, 64(1):22-31, 1996
The relation of patterns of attachment and psychiatric status was studied in 82 non psychotic inpatients and 85 case-matched controls using the Adult Attachment Interview (AAI). AAI transcripts rated(masked to case vs. control status and treatment) were classified using M. Mainand R. Goldwyn's (unpublished manuscript) system. Psychiatric patients,diagnosed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) I and II structured interviews, were more likely to be classified as preoccupied and unresolved with respect to loss or abuse. On Axis 1, anxiety was associated with unresolved status, and AAI scales were able to discriminate depression and eating disorder. On Axis II,borderline personality disorder (BPD) was linked to experience of severe trauma and lack of resolution with respect to it. BPD patients were also rated significantly lower on a scale measuring awareness of mental states. Preliminary outcome results suggest that individuals rated as dismissing on the AAI are more likely to show improvements in psychotherapy.



Title: Source Amnesia, Mis attribution, and the Power of Unconscious Perceptions and Memories 
Author: Bornstein, Robert F.

Source: Psychoanalytic Psychology, 16:155-178, 1999

A review of the empirical literature on implicit(i.e., unconscious) perception and memory reveals that S. Freud's (1910/1955,1914/1956) hypotheses in this area were remarkably prescient in some respects.The implications of experimental research for psychodynamic models of symptom formation, transference analysis, and the curative components of insight-oriented therapy are discussed. Changes in terminology that can help bridge the gap between cognitive science and psychodynamics are outlined, and the heuristic value of strengthening existing connections between these disciplines is emphasized.



Title: Anxiety, Signal Anxiety, and Unconscious Anticipation: Neuroscientist Evidence for an Unconscious Signal Function in Humans 
Author: Wong, Philip S.

Source: Journal of the American Psychoanalytic Association, 47(3):817-841, 1999
A central tenet of psychoanalysis, and arguably of any comprehensive theory of mind, is the existence of a psychological unconscious. Years of clinical investigation into the nature of unconscious processes have facilitated the development of psychoanalysis as a clinical method. Empirical investigations of unconscious mental processes, however, have lagged behind clinical inquiry. With few exceptions, attempts to understand unconscious processes using rigorous experimental controls have remained sequestered in scientific domains other than psychoanalysis, where they have proliferated recently. In view of this recent upsurge of research on unconscious processes outside of psychoanalysis, efforts to integrate such knowledge into general theories of psychopathology and clinical investigation are critical. In this paper, an interdisciplinary approach is taken to the study of one aspect of unconscious mental functioning—what Freud originally termed signal anxiety.Signal anxiety is examined using information from cognitive psychology and learning theory, psychophysiology, behavioral neuroscience, and psychoanalytic theory. Though the original concept of signal anxiety is supported by recent research, it is concluded that signal anxiety is probably best thought of not as the affect of anxiety but as a subset of unconscious mental processes that have a signal function of anticipating danger. Such unconscious anticipatory processes are a general feature of the mind that includes responses to both real and imagined (neurotic) appraisals of a situation. The neurophysiological structures and processes associated with unconscious anticipation in humans are just beginning to be understood.



Title: A New Language for Psychoanalytic Diagnosis 
Author: Shedler, Jonathan 
Source: Journal of the American Psychoanalytic Association, 50(2):429-456, 2002

Many psychoanalysts believe it is impossible to conduct empirical research without eviscerating or trivializing psychoanalytic constructs, and past research efforts have all too often reinforced this view. A new method for studying personality and personality pathology is presented that challenges such beliefs. This method, the Shedler-Westen Assessment Procedure (SWAP), captures the richness and complexity of psychoanalytic constructs and formulations while also providing reliable data for research. The method is being used to develop a new personality disorder taxonomy, as an alternative to the DSM, that is both empirically grounded and psychoanalytically relevant. Its role in psychoanalytic training and supervision is discussed, as is its value as a measure of structural change in psychoanalytic process and outcome research.



Title: Refining Personality Disorder Diagnosis:Integrating Science and Practice 
Author: Shedler, Jonathan and Westen, Drew

Source: American Journal of Psychiatry, 161:1350–1365,  2004

OBJECTIVE: Personality disorder researchers are currently evaluating a range of potential solutions to problems with the DSM-IV diagnostic categories. This article proposes changes to the diagnostic categories and criteria based on empirical findings from a national sample of patients with personality disorder diagnoses. 

METHOD: The Shedler-Westen Assessment Procedure (SWAP-200) is a personality assessment tool designed to capture the richness and complexity of clinical personality descriptions while providing reliable and quantifiable data. A national sample of experienced psychiatrists and psychologists used the SWAP-200 to describe either their conceptions (prototypes) of personality disorders (N=267) or current patients with personality disorder diagnoses (N=530). 

RESULTS:Clinicians’ conceptions of personality disorders and their descriptions of actual patients overlapped with the DSM descriptions but also differed in systematic ways. Their descriptions were clinically richer than the DSM descriptions and placed greater emphasis on patients’ mental life or inner experience. The study identifies potential diagnostic criteria that may be more defining of personality syndromes than some of the current DSM criteria.

CONCLUSIONS: Diagnostic criterion sets should be expanded to better address the multiple domains of functioning inherent in the concept of personality and should more explicitly address patients’ mental life or inner experience. The authors offer recommendations for revision of the diagnostic categories and criteria and also propose a prototype matching approach to personality disorder diagnosis that may overcome limitations inherent in the current diagnostic system.



Title: Countertransference Phenomena and Personality Pathology in Clinical Practice: An Empirical Investigation
Author: Betan, Ephi; Conklin, Carolyn Zittel; Heim, AmyKegley; and Westen, Drew

Source: American Journal of Psychiatry, 162(5):890-898, 2005
OBJECTIVE: This studyprovides initial data on the reliability and factor structure of a measure of countertransference processes in clinical practice and examines the relation between these processes and patients’ personality pathology. 

METHOD: A national random sample of 181 psychiatrists and clinical psychologists in North America each completed a battery of instruments on a randomly selected patient in their care, including measures of axis II symptoms and the Counter transference Questionnaire, an instrument designed to assess clinicians’cognitive, affective, and behavioral responses in interacting with a particular patient. 

RESULTS: Factor analysis of the Counter transference Questionnaire yielded eight clinically and conceptually coherent factors that were independent of clinicians’ theoretical orientation: 1)overwhelmed/disorganized, 2) helpless/inadequate, 3) positive, 4) special/over involved, 5) sexualized, 6) disengaged, 7) parental/protective, and 8)criticized/mistreated. The eight factors were associated in predictable ways with axis II pathology. An aggregated portrait of countertransference responses with narcissistic personality disorder patients provided a clinically rich,empirically based description that strongly resembled theoretical and clinical accounts. 

CONCLUSIONS: Countertransference phenomena can be measured in clinically sophisticated and psychometrically sound ways that tap the complexity of clinicians’ reactions toward their patients. Countertransference patterns are systematically related to patients’ personality pathology across therapeutic approaches, suggesting that clinicians, regardless of therapeutic orientation,can make diagnostic and therapeutic use of their own responses to the patient.



Title: Anxiety, Attributional Thinking, and the Primary Process 
Author: Brakel, Linda A.W. and Shevrin, Howard

Source: International Journal of Psycho-Analysis, 86:1679-1693, 2005
In earlier publications, experimental evidence was provided for the existence of the primary vs. secondary process mental organization posited by Freud. A well-established cognitive categorization test based on attributional and relational similarity was found to map on to primary and secondary principles of mental organization respectively, thus offering the opportunity to test hypotheses drawn from psychoanalytic theory independent of the clinical situation. In prior work, primary process shifts occurred under three different conditions—all predicted by psychoanalytic theory: (1) when stimuli were (subliminal) unconscious; (2) when participants were 3-5 years of age; and (3) when tasks were implicit. In the current study, a fourth condition is examined dealing with the relationship of conscious anxiety to primary and secondary processes. In a naturalistic study, 120 patients waiting in medical center waiting rooms rated how anxious they felt on a 10-point scale and then completed a version of the categorization test alluded to above. Those who reported any anxiety at all showed a significant shift toward primary process categorization over those participants who rated themselves as calm. The implications of this fourth finding are discussed with respect to signal anxiety and symptom formation.



Title: The Relationship of Patient Defensive Functioning and Alliance with Therapist Technique during Short-Term Psychodynamic Psychotherapy 
Author: Ackerman,Steven J.; Blagys, Matthew D.; Hilsenroth,Mark J.; Siefert, Caleb J.; and Weinberger, Joel
Source: Clinical Psychology and Psychotherapy, 13, 20–33, 2006



Title: Fact and Fantasy in Freudian Theory
Author: Kline, P. 
Source: London, Methuen& Co., 1972



Title: Interface of Psychoanalysis and Psychology 
Author: Barron, J.W.; Eagle,M.N.; and Wolitzky, D.L. (Eds.) 
Source: Washington, D.C.,American Psychological Association, 1992



Title: The Scientific Credibility of Freud's Theories andTherapy 
Author: Fisher, S. and Greenberg, R. P.
Source: New York, Basic Books, 1977



Title: The Foundations of Psychoanalysis
Author: Grunbaum, A. 
Source: Berkeley,California, University of California Press, 1984


Title: Subliminally Activated Symbiotic Fantasies: Facts and Artifacts 
Author: Hardaway, Richard A.
Source: Psychol Bull; 107(2):177-95, 1990



Title: Separating Science from Myth in Subliminal Psychodynamic Activation 
Author: Hardaway, Richard A. and Weinberger, Joel
Source: PsycINFO Database Record (c) 2006 APA, all rights reserved 

Reviews subliminal psychodynamic activation(SPA). Eight common criticisms are described and evaluated: (1) SPA data analysis is too liberal; (2) there are enough nonsignificant unpublished SPA studies to offset those showing effects; (3) SPA studies are difficult to replicate; (4) the claims of SPA proponents rely on unpublished studies; (5) SPA stimuli are not really subliminal; (6) experimenter expectancy effects and/or demand characteristics can account for SPA effects; (7) the mediating events said to underlay SPA effects have never been evinced; and (8) alternative explanations for SPA effects are superior to the psychoanalytic ones typically offered. The SPA stimulus for which the most support was found was “Mommy and I Are One.” Oedipal sanction stimuli were also found to yield reliable effects whereas Oedipal prohibition stimuli did not.



Title: Series on Empirical Studies of Psychoanalytical Theories 
Author: Bornstein, R.F. and Masling, J.M.. (1993,1994, 1996, 1998)



Title: Is Psychoanalysis One Science, Two Sciences, or No Science at All? A Discourse among Friendly Antagonists 
Author: Shevrin, H.
Source: Journal of the American Psychoanalytic Association, 43(4):963-986, 1995



Title: Freud Scientifically Reappraised: Testing the Theories and Therapy 
Author: Fisher,S. and Greenberg, R. P. 
Source: New York, John Wiley & Sons, Inc., 1996



Title: The Process of Therapeutic Change Involving Implicit Knowledge: Some Implications of Developmental Observations for Adult Psychotherapy
Author: Stern, D. N. 
Source: Infant Mental Health Journal, 19(3):300-308, 1998

Several aspects of development change that are dependent on interactions between parent and infant are examined for their value in casting light on the process of change in adult psychotherapies. First, the domain of implicit knowledge (where changes necessarily occur in nonverbal infants) is identified. The vast majority of therapeutic change is found to occur in this domain. We then examine the improvised, largely unpredictable, nonlinear environments toward mutual goals that characterize the process of parent-infant and therapist-patient interactions. Finally, we provide a microdescription of these processes and provide a terminology for the "moments" that make up their flow. Of particular importance is the "moment of meeting", in which the participants interact in a way that created a new implicit, intersubjective understanding of their relationship and permits a new "way-of-being-with-the-other". We view "moments of meeting" as the key element in bringing about change in implicit knowledge, just as interpretations are thought to be the key element in bringing about change in explicit knowledge.



Title: The Scientific Legacy of Sigmund Freud: Toward a Psychodynamically Informed Psychological Science 
Author: Westen, Drew
Source: Psychological Bulletin, 124(3):333-371, 1998

Although commentators periodically declare that Freud is dead, his repeated burials lie on shaky grounds. Critics typically attack an archaic version of psychodynamic theory that most clinicians similarly consider obsolete. Central to contemporary psychodynamic theory is a series of propositions about (a) unconscious cognitive, affective, and motivational processes; (b) ambivalence and the tendency for affective and motivational dynamics to operate in parallel and produce compromise solutions; (c) the origins of many personality and social dispositions in childhood; (d) mental representations of the self, others, and relationships; and (e) developmental dynamics. An enormous body of research in cognitive, social, developmental, and personality psychology now supports many of these propositions. Freud's scientific legacy has implications for a wide range of domains in psychology,such as integration of affective and motivational constraints into connectionist models in cognitive science.



Title: Developments in Cognitive Neuroscience: I. Conflict, Compromise, and Connectionism 
Author: Gabbard, Glen O. and Westen, Drew

Source: Journal of the American Psychoanalytic Association, 50(1):53-98, 2002
The strength of psychoanalysis has always been its understanding of affect and motivation. Contemporary developments in cognitive neuro-science offer possibilities of integrating sophisticated, experimentally informed models of thought and memory with an understanding of dynamically and clinically meaningful processes. Aspects of contemporary theory and research in cognitive neuroscience are integrated with psychoanalytic theory and technique, particularly theories of conflict and compromise. After a description of evolving models of the mind in cognitive neuroscience, several issues relevant to psychoanalytic theory and practice are addressed. These include the nature of representations, the interaction of cognition and affect, and the mechanisms by which the mind unconsciously forges compromise solutions that best fit multiple cognitive and affective-motivational constraints.


Title: Developments in Cognitive Neuroscience: II. Implications for Theories of Transference
Author: Gabbard, Glen O. and Westen, Drew

Source:Journal of the American Psychoanalytic Association, 50(1):99-134, 2002
An integration of psychoanalytic theory with contemporary developments in cognitive neuroscience offers a useful perspective on longstanding controversies about the nature of transference, and a better understanding of the precise mechanisms by which transferential processes occur.Contemporary psychoanalytic views of transference are reviewed, and the many processes that constitute transference are described. Two issues that have emerged in different guises for several decades—the role of the analyst in eliciting transference, and the nature of “real” and “transferential” components of the therapeutic relationship—are reconsidered in the light of concepts such as connectionist networks. Although a useful analytic stance is one that allows the patient's enduring dynamics to dominate the analytic field, it is suggested,anonymity is neither a cognitive possibility nor the driving force behind most transference reactions, and the distinction between “real” and “transferential”perceptions is one of therapeutic interest, not of mechanism. Certain features of the analytic situation make some dynamics more likely than others to enter the treatment relationship, notably those related to authority, intimacy and attachment, and sexuality. Transference reactions are best understood as constructed from a combination of the patient's enduring dispositions to react in particular ways under particular conditions; features of the analytic situation and of the analyst; and interactions between patient and analyst.These reactions do not unfold ineluctably from the patient's mind in the consulting room, nor are they cognitive constructions of the patient-analyst dyad or co-constructions of relatively equal partners exerting their influence on the analytic field.



Title: Effectiveness of Long-term Psychodynamic Psychotherapy

Author:  Leichsenring, F.; Rabung S.

Source: Journal of the American Medical Association, 300(13):1551-1565, 2008

CONTEXT: The place of long-term psychodynamic psychotherapy (LTPP) within psychiatry is controversial. Convincing outcome research for LTPP has been lacking.

OBJECTIVE: To examine the effects of LTPP, especially in complex mental disorders, ie, patients with personality disorders, chronic mental disorders, multiple mental disorders, and complex depressive and anxiety disorders (ie, associated with chronic course and/or multiple mental disorders), by performing a meta-analysis.

DATA SOURCES: Studies of LTPP published between January 1, 1960, and May 31, 2008, were identified by a computerized search using MEDLINE, PsycINFO, and Current Contents, supplemented by contact with experts in the field.

STUDY SELECTION: Only studies that used individual psychodynamic psychotherapy lasting for at least a year, or 50 sessions; had a prospective design; and reported reliable outcome measures were included. Randomized controlled trials (RCTs) and observational studies were considered. Twenty-three studies involving a total of 1053 patients were included (11 RCTs and 12 observational studies).

DATA EXTRACTION: Information on study characteristics and treatment outcome was extracted by 2 independent raters. Effect sizes were calculated for overall effectiveness, target problems, general psychiatric symptoms, personality functioning, and social functioning. To examine the stability of outcome, effect sizes were calculated separately for end-of-therapy and follow-up assessment.

RESULTS: According to comparative analyses of controlled trials, LTPP showed significantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. With regard to overall effectiveness, a between-group effect size of 1.8 (95% confidence interval [CI], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups (P = .002). According to subgroup analyses, LTPP yielded significant, large, and stable within-group effect sizes across various and particularly complex mental disorders (range, 0.78-1.98).

CONCLUSIONS: There is evidence that LTPP is an effective treatment for complex mental disorders. Further research should address the outcome of LTPP in specific mental disorders and should include cost-effectiveness analyses.



Title: 8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual

Author: Bateman, A.; Fonagy, P.

Source: American Journal of Psychiatry, 165:631-638, 2008

OBJECTIVE: This study evaluated the effect of mentalization-based treatment by partial hospitalization compared to treatment as usual for borderline personality disorder 8 years after entry into a randomized, controlled trial and 5 years after all mentalization-based treatment was complete.

METHOD: Interviewing was by research psychologists blind to original group allocation and structured review of medical notes of 41 patients from the original trial. Multivariate analysis of variance, chi-square, univariate analysis of variance, and nonparametric Mann-Whitney statistics were used to contrast the two groups depending on the distribution of the data.

RESULTS: Five years after discharge from mentalization-based treatment, the mentalization-based treatment by partial hospitalization group continued to show clinical and statistical superiority to treatment as usual on suicidality (23% versus 74%), diagnostic status (13% versus 87%), service use (2 years versus 3.5 years of psychiatric outpatient treatment), use of medication (0.02 versus 1.90 years taking three or more medications), global function above 60 (45% versus 10%), and vocational status (employed or in education 3.2 years versus 1.2 years).

CONCLUSIONS: Patients with 18 months of mentalization-based treatment by partial hospitalization followed by 18 months of maintenance mentalizing group therapy remain better than those receiving treatment as usual, but their general social function remains impaired.