PERSPECTIVES

The Place of Psychoanalytic Treatments Within Psychiatry

Glen O. Gabbard, MD; John G. Gunderson, MD; Peter Fonagy, PhD

sychoanalytic 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 multisite process and outcome study is proposed. Arch Gen Psychiatry. 2002;59:505-510
As psychiatry has grown increasingly dominated by the neurosciences, the role of psychoanalytic treatments within psychiatry has become more and more controversial.1-4 The emphasis on empirically validated treatments has raised the clinical trial with randomized controlled design to the level of the gold standard that determines whether efficacy of a particular therapeutic modality has been demonstrated. Psychiatrists who ascribe to this view can now dismiss claims for therapeutic efficacy of psychoanalytic therapies in the absence of data that adhere to this standard. Detre and McDonald4(p203) observed, Although long-term, socalled intensive therapy has been dying for years, some of our professions leaders cling fiercely to the illusion that it works and that only psychiatrists can do it. However, since we have proof only of its high cost and not its effectiveness, psychiatrys reluctance to admit that the emperor is indeed naked only increases public skepticism. This communication is born out of our conviction that psychoanalytic treatments, by which we mean psychoanalysis and psychoanalytic therapies of varying frequency and duration, must remain closely integrated with psychiatrys repertoire of treatments, for the welfare of both psychoanalysis and psychiatry. While we will review evidence supporting the usefulness of psychoanalytic therapies, we present these data with full recognition that the findings from these studies are not sufficiently compelling to persuade those who are skeptical. The existing evidence does, however, set the stage for identifying ways that more compelling evidence can be acquired and for a discussion of why these therapies retain a unique and potentially crucial role for treating some forms of psychiatric illness. The threatened divorce of psychiatry from psychoanalysis is driven by ideological, economic, and political forces. Their common offspring, psychoanalytic psychotherapy, is at risk of being sacrificed if scientific methods cannot be developed that will further test its practitioners claims of efficacy.

See also pages 497, 499, and 501

In the past 2 decades, numerous studies have demonstrated the effectiveness of medications and short-term psychotherapies in treating the symptoms of specific Axis I conditions, such as depression and anxiety disorders. Nevertheless, longitudinal research studies have shown that these disorders are hardly episodic conditions and may require ongoing treatment.5-9

From the Department of Psychiatry, Baylor College of Medicine, Houston, Tex (Dr Gabbard); McLean Hospital, Belmont, Mass (Dr Gunderson); and Psychoanalysis Unit, Philips House, University College London, London, England (Dr Fonagy).

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Psychoanalytic treatments may be necessary when other treatments are not effective, or for the residual, often less manifest, problems that persist after brief interventions have done their best. Psychoanalytic therapies also have the potential (not yet tested) to affect long-range vulnerability by altering the way the patient deals with stressors and therefore to make more enduring changes. This potential to be useful for patients who do not respond to briefer treatments warrants further research into these modalities. A HIERARCHY OF EVIDENCE The development of a more empirically grounded framework for the use of psychoanalytic therapies is a process that involves many sources of evidence. In our view, both efficacy and effectiveness research are necessary. Efficacy studies, with a limited number of therapists and patients in a carefully controlled setting using a manualized treatment, establish that a specific approach improves a specific condition. Effectiveness studies then test the treatment on a larger scale with more typical patients and therapists. Both types of studies typically use randomized controlled designs. We emphasize that there is value in a hierarchy of data sources that together provide a framework of evidence for the usefulness of psychoanalytic treatments.1,10,11 Efficacy and effectiveness studies are together at the top of the hierarchy because of their complementary nature. Even within randomized controlled trials there are varying levels of evidence. The most rigorous variant is comparison of the study treatment with a well-established alternative treatment, which makes it possible to determine whether the specificity of the research treatment may provide different outcomes than the established alternative treatment. The second most rigorous variant within efficacy studies would be the use of a placebo treatment as a control. For example, Strupp and Hadley12 compared trained psychodynamic and experiential clinicians with college professors noted for their warmth and empathic understand-

ing who listened to the patients concerns. In the current climate of ethical dilemmas regarding research, placebo controls are more controversial. The third most rigorous form of randomized controlled trial would be to use a treatment as usual control. The lack of systematic data on what was done in these treatments makes the determination of specificity difficult. The least rigorous of the variants of efficacy studies involves wait-list controls who do not receive any treatment. In designs of this nature, researchers cannot determine whether the outcome after treatment is due to specific components of the therapy or occurs simply because the therapist spent time with the patient, compared with the controls, who spent no time with therapists. The major point here is that evaluation of therapies of any duration is hard to envision without a control group. Outcomes of treatment cannot be distinguished from the natural course of the disorder without control subjects. Control groups of long-term treatments should ideally involve alternative extended treatments, but these are difficult to arrange in most studies. Hence, treatment as usual is often used as an alternative. Randomized controlled trials with manualized treatment in homogeneous samples are more reliable than trials in which randomization was not possible and the treatment cannot be described. This hierarchy of evidence is in line with generally accepted criteria described in the Cochrane Reviewers Handbook 4.013 and other sources.14,15 Moving down the hierarchy, the next level of evidence involves prospective pre-post studies that measure patients before and after the intervention to document the nature and extent of the changes. Here, for example, one could use a standardized treatment, offered to a wide range of patient types, and then determine for what patient groups it does best or worst. The next level down would involve case series that are often orchestrated by a clinical innovator in collaboration with colleagues who have been personally trained by the innovator. These case series support hypotheses about the expectable time frames for change.

Below this level in the hierarchy one would find case reports that document a new intervention and its purported benefit in terms of the specific hypothesized outcome. The lowest level would consist of clinical innovation, which involves the development of a therapy with a persuasive rationale. Regrettably, this level of evidence is the only support for most psychoanalytic therapies. With a few exceptions, psychoanalytic treatments have not evolved to the point where the highest level of the hierarchy has been reached. The psychodynamic approach has been established by a substantial body of research on brief psychodynamic therapy. A meta-analysis performed on 26 studies between 1974 and 199416 found that short-term psychodynamic therapy was equally effective as other therapies at posttreatment follow-up. It even showed a slight superiority in follow-up assessment. In addition, 3 separate studies have demonstrated that accurate interpretation of core conflicts predicts better treatment outcomes within sessions and across sessions.17-19 When we examine psychoanalysis and intensive psychoanalytic therapy, we find only 4 outcome studies using the highest levels of our hierarchy. In the Boston Psychotherapy Study,20 patients with schizophrenia who received supportive therapy were compared with those who were provided with psychoanalytic therapy at a frequency of 2 or more times a week by experienced psychoanalytically oriented therapists. While certain outcome measures seemed to improve differentially in each group, overall no significant advantage was conferred on patients who were treated with psychoanalytic therapy.21 A study of psychoanalytic therapy (3 to 4 sessions per week) for 11 hospitalized diabetic children had profound and lasting effects on their health compared with a comparable sample of diabetic children who received standard medical treatment.22 The treatment lasted only 15 weeks, so the study is relevant to intensive psychoanalytic therapy but not to the study of extended psychoanalytic therapy.

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Heinicke and Ramsey-Klee23 compared intensive psychoanalytic psychotherapy (4 times a week) to once-a-week sessions for children with learning difficulties. This randomized controlled trial involved treatments lasting more than a year. The children who were seen once a week showed a greater rate of improvement than those receiving 4-times-weekly sessions. At the time of follow-up, however, the children who had 4-times-weekly sessions showed much greater improvement. In a more recent study, 38 patients with borderline personality disorder were randomly assigned to a psychoanalytically oriented partial hospital treatment or to standard psychiatric care as a control group.24 The primary treatments in the partial hospital cell consisted of once-weekly individual psychoanalytic psychotherapy and 3-timesweekly group psychoanalytic psychotherapy. The control subjects received no psychotherapy. At the end of treatment at 18 months, the patients who received the psychoanalytically oriented treatment showed significantly more improvements in depressive symptoms, social and interpersonal functioning, need for hospitalization, and suicidal and self-mutilating behavior. These differences were maintained during an 18-month posttreatment follow-up period with assessments every 6 months.25 Moreover, the treatment group continued to improve during the 18-month follow-up period. The scarcity of efficacy data based on controlled clinical trials is understandable, given the particular methodologic problems associated with studying long-term intensive therapy. Our group described these problems in more detail elsewhere.1 In brief, the cost of a longterm follow-up study would be prohibitively high; a suitably matched control group is difficult to recruit; and uncontrolled variables such as illness, life events, Axis I disorders, and medication changes would likely affect the meaningfulness of the results. Also, self-selection of treatment in long-term therapy or analysis is of critical importance. Patients not given the treatments they desire might well drop out.

In Sweden the Stockholm Outcome of Psychoanalysis and Psychotherapy Project26 was able to follow up a large number of patients treated with psychoanalysis and psychoanalytic therapy that was subsidized by national health insurance and provided by private practitioners. This study can best be categorized as a large pre-post design. Random assignment was attempted but was unsuccessful. Some patients refused to be assigned, and others who agreed to be assigned did not get the treatment they preferred, so they sought it privately. The patient sample included 756 persons who were subsidized for up to 3 years in psychoanalysis or psychotherapy or on the respective waiting lists for subsidization of those treatments. Complete data for 3 panel waves were obtained from a group of 331 persons in various phases of long-term psychodynamic psychotherapy and from a group of 74 persons in various phases of psychoanalysis. The psychoanalytic treatments were defined as occurring 4 to 5 times a week, while psychotherapy consisted of 1 to 2 sessions per week. In measurements of symptomatic outcome using the Symptom Checklist 90, improvement during the 3 years after treatment was positively related to treatment frequency and duration, with patients in psychoanalysis doing better than those in psychoanalytic psychotherapy. Patients in psychoanalysis continued to improve after termination, a finding not generally noted in outcome studies of other psychotherapies. Another large pre-post study of 763 children who were examined and given psychoanalytic treatment at the Anna Freud Centre in London, England, yielded data that suggested which patients were more likely to benefit from analysis.27,28 Children with phobias appeared to benefit significantly from psychoanalysis, while those with depression did not. While children with severe emotional disorders (3 or more Axis I diagnoses) did surprisingly well in psychoanalysis, they did poorly in once- or twicea-week psychoanalytic psychotherapy. Children with conduct problems did consistently worse than children with emotional difficulties of equal severity. Children younger

than 12 years made more impressive gains with intensive treatment at 4 to 5 times per week than with nonintensive treatment at 1 to 3 times per week. Adolescents, on the other hand, did not appear to benefit from increased frequency, but the duration of the treatment was correlated with better outcomes. This study nicely illustrates how the findings of research are likely to surprise and inform clinical practitioners. Several prospective followalong studies using a pre-post design have suggested substantial improvements in patients given psychoanalytic therapies for personality disorders.29-32 Additional data33 from one of these studies suggest that gains from 1 year of dynamic therapy were maintained at 5-year follow-up. Uncontrolled studies, however, particularly those with relatively small sample sizes and clinical populations whose condition is known to fluctuate wildly, cannot yield data of consequence concerning what type of treatment is likely to be effective for whom. The Research Committee of the International Psychoanalytical Association prepared a comprehensive review of the studies of psychoanalytic treatment carried out in North America and in Europe.34 (Twenty-six studies were reviewed in the second edition of this detailed 330-page report, which is available from the IPA [e-mail: ipa@.ipa.org.uk for details].) The committee concluded that existing studies do not adequately demonstrate that psychoanalysis is efficacious relative to either an alternative method of treatment or an active placebo. Studies are typically limited by obvious problems in methods and design: failure to use standardized diagnoses, inadequate description of treatment procedures, failure to control for selection biases in sampling, the absence of analyses of subjects who joined the study but later dropped out (intent to treat), the use of inexperienced therapists, little homogeneity in patient groups, lack of manualization of the treatment interventions, lack of randomized assignment, failure to standardize measures of outcome, lack of

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independent assessment of outcome, and lack of statistical power, to name several. Nevertheless, a number of studies with state-of-the-art methods testing psychoanalysis are ongoing and have the potential during the next decade to provide further evidence about the value of psychoanalysis. Despite the limitations of the completed studies, evidence across a significant number of pre-post investigations suggests that psychoanalysis appears to be consistently helpful to patients with milder (neurotic) disorders and somewhat less consistently so far for other, more severe groups. Of course, no definitive conclusion can be reached without a control group. Across a range of uncontrolled or poorly controlled cohort studies, mostly carried out in Europe, longer intensive treatments tended to have better outcomes than shorter, nonintensive treatments; the impact of therapy was apparent beyond symptomatology, in measures of work functioning and reductions in health care costs; and growth continued after the therapies ended. FUTURE DEVELOPMENTS We now propose a path for the development of an empirical framework for psychoanalytic therapies within 21st-century psychiatry. By placing the focus of explanation into an intrapsychic domain that is not necessarily compatible with controlled observations and testable hypotheses, psychoanalysis has deprived itself of the interplay between data and theory that has contributed so much to the growth of modern science. In the absence of data, psychoanalysts have frequently been forced to fall back on either the indirect evidence of clinical observation or argument by authority. In suggesting this alternative strategy, we are not advocating a return to discredited residues of logical positivism.35,36 Rather, we anticipate that, by embracing a research agenda, psychoanalysts will open their discipline to the possibility of evidence inconsistent with their expectations.37 We feel confident that both advocates and critics of psychoanalytic therapies will be forced to rethink what they believe they already know. We will divide our proposal for

a research agenda into 3 discrete categories: training, standardized assessment, and the development of measures. Training No science background was necessary in the early decades of the development of psychoanalysis. Many giants in the field, such as Erik Erikson, Anna Freud, and Melanie Klein, came from backgrounds in the arts, philosophy, or education. Research continues to play an insignificant part in the training of psychoanalysts.38,39 Only a minority of the training institutes in the United States include research as part of their curriculum, and many analysts are explicitly hostile to research beyond traditional case reports. To begin to change the attitudes and infrastructure about research, we propose that psychoanalytic institutes provide guidelines on the recent research literature so that component institutes can incorporate these articles into their curricula. Second, we propose that institutes expand their vision to make all institute-sponsored cases part of a database available to interested research scientists. Third, we encourage a concerted initiative such as the one organized by the International Psychoanalytical Association to develop a group of psychoanalytic researchers through a systematic training program.37 Standardized Classification of Patient Types A significant gap in the field, which has hindered the cumulative construction of a psychoanalytic knowledge base, is the absence of even a rudimentary classification system to describe clinical cases. As a first step, the psychoanalytic community needs to adopt a classification system that, even if debatable in its particulars, makes their description of cases understandable to others. The introduction of a generally accepted nosology should make it possible to identify major diagnostic categories, such as affective disorders, personality disorders, and eating disorders. The International Psychoanalytical Association should

proactively lead the process by bringing together experts in the field and generating a consensus system of diagnoses and their definitions. Swedish clinicians at the Karolinska Institute, Stockholm,40 and a group of German psychoanalysts have already evolved operationalized psychodynamic diagnoses that could function in conjunction with or independently of DSM-IV.41,42 Training institutions need to collaborate to ensure that the categories are used with an adequate level of consistency. Outcomes should also be rated, and if the data were pooled, psychoanalysts would have a substantial amount of information concerning which diagnostic entities are most likely to respond to psychoanalytic treatment.1 Of course, even if improvement is observed in such samples, that improvement cannot be causally linked to the psychoanalysis in any definitive way.43 Yet it is hard to justify undertaking an expensive trial for groups of patients for which naturalistic studies have identified relatively little change. A formal assessment of psychoanalytic patients is thus an essential precondition for controlled studies of the therapeutic outcome of psychoanalysis. Developing Measures Once the decision to explore the effectiveness of psychoanalysis is made, the psychoanalytic researcher, like all psychotherapy researchers, is confronted with 2 closely related demands. The first is a measure of the outcome of psychoanalysis. The second is the verification that psychoanalytic treatment has indeed taken place. This latter requirement involves 2 challenges: first, the description of psychoanalytic treatment in a form that permits assessment that any particular analyst has performed a treatment that may be so designated, and second, a method of demonstrating therapist adherence and competence in the delivery of a specific treatment. To measure adherence we must use a manual. Two manuals for extended psychoanalytic therapy or psychoanalysis have been devel-

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oped (Clarkin et al44 and P. Fonagy, PhD, R. Edgcumbe, MA, M. Target, PhD, J. Miller, and G. Moran, PhD; Contemporary Psychodynamic Child Therapy: Theory and Technique, unpublished manuscript; 1997) but these have yet to be rigorously tested. The difficulties in manualizing psychoanalytic treatments are obvious. Manuals usually describe brief treatments of 12 to 20 sessions in a session-bysession sequence. They are most successful when treatments do not depend on the productivity and nature of the individual patient, when the theoretical base provides a relatively unambiguous formulation of the disorder, and when treatment techniques may be directly linked to these formulations. Psychoanalysis is a long treatment that relies on the material brought by the patient. Its techniques are easy to prescribe but clearly depend on creativity and intuition for competent application. Thus, adherence at the level of strategy does not necessarily imply competence at the level of technique. Indeed, studies that have manualized psychoanalytic therapy have found adherence to be a major obstacle.45 Psychoanalytic therapists tend to value flexibility and autonomy, and they do not appreciate the constraints inherent in manualized treatments.46 Perhaps the most significant challenge facing those who would like to provide a manual of psychoanalytic technique is the loose relationship between psychoanalytic theory and clinical practice.47 It is impossible to achieve one-to-one mapping between psychoanalytic therapeutic technique and any major theoretical framework. Theory and practice have progressed at very different ratespractice has changed in only minor ways relative to the major strides made by theories. Moreover, psychoanalytic theory is largely not about clinical practice. Even when psychoanalysts are working within the same theoretical framework, they find great difficulty in arriving at a consensus as to the presence or absence of a psychoanalytic process.48 A naturalistic indication of technical variation across training centers and across analyses within

training centers would be a useful first step in starting to establish empirically the relationship between theoretical orientation and technique. A standard measure could be used by all participating analysts with the aim of establishing common techniques and their relationship to theory and outcome. In the absence of tape-recording, these relationships would be to hypothesized rather than observed techniques. Concurrent studies could attempt to establish the nature of the systematic association between hypothesized technical features of a treatment and the profile of actual technical aspects. A wide range of measures is potentially available to monitor the processofpsychoanalytictherapy.Wecan envision the collection of a minimal psychoanalytic data set that would include measures of both process and outcome. A most promising approach makes use of a relatively simple instrumentthe Psychotherapy ProcessQ-set.49 This100-iteminstrument provides a basic language for the description and classification of treatment processes in a form suitable for quantitative analysis. Entire therapeutic hours are rated by sorting the Q items into a prespecified normal distribution. Potential underlying structures of interaction are identified, and time-series analysis is then used to assess changes over time by exploring the temporal unfolding of variables. The measure succeeds in operationalizing characteristic patterns of interaction between patient and analyst.50 This approach relies heavily on videotaping or audiotaping of sessions, which makes the demonstration of treatment integrity much more compelling. A similarly straightforward approach could be taken to the measurement of psychoanalytic outcome. The minimum psychoanalytic data set could include baseline and annually collected outcomes data from analyst and patient. Relatively simple outcome measures are readily available. This is comparatively easy in the symptom domain where self-report measures such as the Symptom Checklist 90Revised51 and the Beck Depression Inventory52 are commonly used in psychotherapy research. Similarly, the Global Assess-

ment of Functioning ratings could readily represent the therapists perspective. A new self-report instrument, with considerable promise for a simple generic measure of outcome, is a questionnaire in use by Barkham and colleagues53 for the standard assessment of adult psychosocial treatments in the British health care system. The Short Form 3654 might also be used to measure the impact on physical symptoms. STUDY PROPOSAL What we are proposing here is a multisite process and outcome study in which all patients undertaking psychoanalysis under supervision become subjects in a rudimentary investigation of the outcome of psychoanalytic treatment. Sampling is critical here. It is essential that all sites participating recruit all trainee analysts for the investigation. Given the centralized organization of current psychoanalytic training,55 this goal may be achieved with relative ease. Baseline, annual, and end of treatment information (process and outcome) could be collected on all patients, at least from the therapists perspective, but preferably also from the patients perspective. Outcome information may then be related to both patient characteristics and selected process variables to answer basic questions concerning the appropriateness of the treatment method to specific patient groups, the choice of maximally effective techniques, and possible interactions between techniques and client groups. These data, if drawn from a substantial sample and if collected with reasonable rigor, could represent a significant step toward answering key questions. The proposed study would provide data that would offer evidence of whether psychoanalytic therapies differ in their effectiveness with different patient groups, techniques, and the timetable and sequence in which change occurs. These results, in turn, would frame more discrete hypotheses and more rigorously controlled outcome studies. In considering indications for psychoanalysis, such as treatment failure with psychotherapy, a cost-benefit analysis could be incorporated. Of particular interest would be individuals whose phar-

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macotherapy or alternative, less intensive, psychosocial treatments have failed by some criterion and for whom psychoanalysis was a success. One could envision a matrix of potential achievements by clinical conditions, which is populated by the cheapest available treatment options. In some conditions, such as severe personality disorders, more intensive and extended treatment may ultimately be more cost-effective.56 Submitted for publication January 10, 2001; final revision received June 11, 2001; accepted September 11, 2001. Corresponding author and reprints: Glen O. Gabbard, MD, Department of Psychiatry, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 (e-mail: ggabbard @bcm.tmc.edu).
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