Recent years have seen an explosion in EDT and other dynamic psychotherapy outcome research. This includes many positive studies in the treatment of depression. Allan Abbass, professor, psychiatrist, author and founding Director of the Centre for Emotions and Health at Dalhousie University in Halifax, Canada, has been at the forefront of these efforts. We are pleased to welcome Dr. Abbass and other members of our research community to present summaries of recent outcome studies.
Research Symposium Presentations
The Efficacy of Experiential Dynamic Therapy for Psychiatric Conditions: A meta-analysis of Randomized Controlled Trials
In order to evaluate the efficacy of Experiential Dynamic Therapy (EDT) for psychiatric conditions, we conducted a meta-analysis of randomized controlled trials focusing on therapy models derived from the work of Malan (1979) and/or Davanloo (1990, 2000, 2005). Twenty-eight studies published between 1978 and 2014 were included, encompassing 1782 adult patients with mood, anxiety, personality or mixed disorders. Across outcome domains, medium size between-group effects (Cohen’s d ranging from 0.39 to 0.65) favored EDT over inactive controls at post-treatment, as well as in symptom measures at follow-up. We found no differences between EDT and active treatments (e.g., medication, CBT, manualized supportive therapy) at post-treatment, but EDT outperformed supportive therapy at follow-up (d = 0.75). In terms of within-group effect sizes, EDT was associated with large improvements in general psychiatric symptoms (d = 1.11), depression (d = 1.33) and anxiety (d = 1.09), as well as small to moderate gains in interpersonal problems (d = 0.55) and global functioning (d = 0.86). Small but significant effects suggested continued improvement between post-treatment and follow-up. Subgroup analyses indicated that EDT may be particularly efficacious in depressive disorders and that individual EDT had larger effects compared to group treatment. Additionally, EDT performed better in higher quality studies. We conclude that EDT is a promising treatment for psychiatric conditions in adults. Further high quality studies evaluating contemporary versions of EDT in specific psychiatric conditions are warranted. The presentation will include updated data from studies published after this meta-analysis was conducted.
Lilliengren, P., Johansson, R., Lindqvist, K., Mechler, J., & Andersson, G. (in press). Efficacy of Experiential Dynamic Therapy in psychiatric conditions: A meta-analysis of randomized controlled trials. Psychotherapy.
Patients’ Affective Processes within Initial Experiential Dynamic Therapy Sessions
Presenters: Katie Aafjes-van Doorn,, Peter Lilliengren & Angela Cooper
Psychotherapy process studies have indicated that patients’ in-session emotional arousal may be a key component of effective psychotherapy. Therefore, an important task for further psychotherapy process research is to elucidate the processes that contribute to adaptive affect experiencing during therapy. The aim of this study was to investigate the relationships between patients’ levels of insight, motivation and inhibitory affects and the patients’ corresponding level of adaptive affect experiencing in initial Experiential Dynamic Therapy (EDT) sessions. Four hundred and sixty-six 10-minute video segments from 31 initial sessions were rated using the Achievements of Treatment Objectives Scale (ATOS). A series of multi-level growth models were estimated to predict patients’ adaptive affective experiencing (Activating Affects) across session segments. In line with our expectations, higher levels of Insight and Motivation related to higher levels of Activating Affects per segment. Contrary to expectations, however, lower levels of Inhibitory Affects were not associated with higher levels of Activating Affects. Further, a time-lagged model showed that Insight, Motivation or Inhibition in the previous segment did not predict Activating Affects in the next segment, possibly indicating that 10-minute segments may be suboptimal for testing temporal relationships in affective processes. Our results suggest that when therapists seek to intensify patients’ immediate affective experiencing, they should focus on increasing insight into defensive patterns and, in particular, motivation to give them up. Reducing inhibitory affects may be less of a priority in an initial EDT session. Implications for EDT theory and further research are discussed.
Aafjes-van Doorn, K., Macdonald, J., Stein, M., Cooper, A. M., & Tucker, S. (2014). Experiential Dynamic Therapy: A Preliminary Investigation Into the Effectiveness and Process of the Extended Initial Session. Journal of Clinical Psychology, 70(10), 914-923.
Antidepressant medications alone are of limited effect in real world study. Preliminary research suggests that psychodynamic treatments should be formally studied for patients not responding to medications. Furthermore, the underlying mechanisms which relate to the outcome of therapy are often not clearly understood. Process-outcome research which examines the active ingredients underlying psychological interventions is called for in order to inform the optimisation of talking therapies.
Findings from The Halifax Treatment Resistant Depression Trial
The Halifax Treatment Refractory Depression Project uses a randomized parallel group design to examine the effects of ISTDP for depressed patients non-remitting following antidepressant treatment. The effects of 20-session time-limited ISTDP are judged through comparison against secondary care TAU. Sixty participants were recruited and allocated to treatment (ISTDP N=30; TAU N=30). Post-treatment findings will be presented on the clinical efficacy of ISTDP treatment. The study also includes several theoretically plausible moderator (quality of patient object relations, comorbid personality disorders) and mediator variables (alexithymia, defence style) to examine a potential relationship with change in depressive symptoms by treatment group. Finally, all ISTDP sessions were coded using the achievement of therapeutic outcomes scales (ATOS) to explore the relationship between level and/or change in patient insight, affect experiencing and motivation within sessions and level and change in depression severity over the course of treatment. Discussion on the findings of these process-outcome analyses of ISTDP will inform an understanding of the key specific therapeutic ingredients.
A Clinical Trial of Short-Term Psychodynamic Psychotherapy (STPP) as a Frontline Treatment for Severe, Complex and Treatment Resistant Disorders
Presenters: Susan Hajkowski and Stephen Buller
This is a report of a pre-post, case series, clinical trial of ISTDP as an empirically supported Short-Term Psychodynamic Psychotherapy (STPP), with clinical developments for the target population. The study investigates the effectiveness of ISTDP for patients with severe and complex psychiatric disorders in the context of a frontline assessment team in a UK, secondary public mental health service. A range of patient reported and clinician reported outcome measures were used to study the implementation and effectiveness of ISTDP in this setting. Measures were used at each session enabling pre-post outcome analysis and case tracking. Results from analysis of pre-post data suggest that there has been statistically significant improvement on all measures, with good effect size, in a relatively small number of sessions. A comparison of within-group analyses offers a critical perspective of both Jacobson-Truax (JT) and Percentage Improvement (PI) methods, with >75% of patients recovered and improved. These results give support for the use of ISTDP with the target patient population. Consideration of different methods of data analysis, and adoption of session-by-session recording of outcome measures, indicate potential to elaborate change mechanisms from process-outcome findings. Preliminary findings add to the growing body of evidence for the effectiveness of STPP particularly when implemented for patients with severe and complex disorders in a secondary mental health service.
The DSM5 introduced important changes in diagnosis of depressive disorders. The inclusion of a diagnosis for persistent depressive disorders (PDD) builds on research showing that depression will affect one in six men and one in four women in their lifetime, and that 50% of people who recover from their first episode of depression will experience a relapse. 80% of people experiencing two episodes will experience additional episode and people with a history of depression will experience between five and nine episodes of depression in their lifetime.
Inpatient therapy for treatment resistant depression using short term dynamic psychotherapy: intitial findings from a process study
The presentation will be on a naturalistic study of change mechanisms for treatment resistant depression in inpatient therapy using affect phobia therapy and a short-term interpersonal dynamic therapy. The patients accepted in the study have had on average four failed treatment attempts before entering this therapy, as well as a an average of 17 years since symptom debut. Patients accepted to the treatment program are measured three times a week on symptoms, common factors and process variables in therapy for the 13-week duration of the treatment program. This allows for a detailed investigation of the change process within individual therapies. The presentation will report on the relationships between specific common factors, affective processes, cognitive processes and their relationships with outcome. The purpose of the study is to better understand the processes that need to unfold in order to change ingrained patterns of functioning in depressive patients.
Experiential Dynamic Therapy through the Internet: Current state of evidence
Department of Clinical Neuroscience, Section of Psychiatry
Karolinska Institute, Stockholm, Sweden
Department of Psychology
Stockholm University, Sweden
Department of Behavioural Sciences and Learning
Linköping University, Sweden
We have completed two randomized controlled trials that investigated the efficacy of Internet-delivered Experiential Dynamic Therapy in the format of guided self-help. The treatment was based on the book ’Living like you mean it’ by Ronald J. Frederick. In the first study, we tested the treatment among 100 individuals with mixed depression and anxiety disorders. Large effects were observed on depression and moderately large effects on symptoms of anxiety. In the second study, we tested the treatment among 72 individuals with DSM-V diagnosed social anxiety disorder. Large effects were observed after treatment, that were stable in long-term follow-up.
In the talk we will present an overview of the model and summarize the evidence from our clinical trials. Furthermore, we will show the actual treatment and the web-based user interface.
Dr. Abbass will summarize results from his Short-Term Psychodynamic Psychotherapy (STPP) research from the Centre for Emotions and Health at Dalhousie University in Canada. This will include a new Meta-analysis of STPP for Depression, a study of STPP for Depression and Personality Disorder, and The Cochrane Review Overall Evidence for ISTDP for Depression.
Driessen E, Hegelmaier L, Abbass A, Barber J, Dekker J, Van H, Jansma E, Cuijpers P. The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis update. Clin Psychol Rev. 2015 Dec;42:1-15.
Abbass A, Town J, Driessen E. The efficacy of short-term psychodynamic psychotherapy for depressive disorders with comorbid personality disorder. Psychiatry, 2011, 74 (1) 58-71.