Abstract
Areviewer should not earn his reviewing fee by quoting directly from the preface to the book, but I cannot improve on Peter Fonagy's concluding paragraph:
This is a pioneering volume of work in progress. It is important and exciting work by talented pioneers who have responded effectively to an intellectual as well as a professional call. It is clear from the variety of findings reported in this stimulating volume that many of the traditional ideas concerning psychoanalytic psychotherapy will need to be revised. This does not signal the demise of the psychoanalytic approach but, rather, indicates the great potential for further development of its knowledge base.
I have argued in the past that outcome studies into psychoanalytic treatments cannot ever approach the ‘gold standard’ of the double-blind controlled study expected of similar studies of the efficacy of psychopharmacological agents, without causing disturbance to the psychoanalytic therapies themselves.
Well, the studies reported in this slim volume come pretty close!
Although almost any study in psychiatry can be criticized on methodological grounds if one tries hard enough, any fair-minded personwill agree that many of the studies described in this book attempt to meet past shortcomings with astounding vigour.
The book is the seventh in the EFPP/Karnac Clinical Monograph Series. ‘EFPP?’ you might ask. European Federation for Psychoanalytic Psychotherapy in the Public Health Services! Yes, in the public health services!
All the contributors to the seven chapters reporting the studies come from Germany (mainly), the UK and Sweden – all countries where psychoanalytic psychotherapy is available in the public sector, either because such therapy is available by government subsidy (Germany and Sweden) or with the national health scheme (UK). Of course, there is a vested interest in such governments having these expensive services evaluated. The various researchers have come up with creative and rigorous study designs to approach achieving these ends.
Although it has been claimed that psychotherapeutic treatments are among themost researched in medicine [1] and conscientious attempts have been made to evaluate them since the efforts of Jerome Frank in the 1960s [2], sustained and largely valid criticisms as to inadequate method have been levelled against such studies.
In the present volume, comprehensive efforts to develop appropriate valid instruments are reported; use of independent raters is included; random allocation to study groups, as well as attempts to match patients in these groups is undertaken. The only ‘gold standard’ criterion which is not – and cannot – be catered to is that involving ‘double-blindness’: single, perhaps yes, but double… no.
As Fonagy says in his foreword quoted earlier, this is a pioneering volume of work in progress. The German and Swedish researchers are not reporting unequivocally complete outcome studies (yet) – but rather that creative efforts at developing suitable instruments have been successful and that earlier justified criticisms have been addressed. Early indications are that there is a real difference between formal psychoanalytic treatment conducted at four- and five-times per week and lesser intensity psychoanalytically oriented treatments. First, that ‘full’ psychoanalysis has better and more enduring results, but, second, that lesser frequency psychotherapy with ‘orthodox’ psychoanalysts and with less ‘orthodox’ therapists have different outcomes seems to have come as a surprise, in that ‘orthodoxy’ fares less well in the less intensive therapy.
The tools developed which reveal these differences include ones intended to assess structural change – rather than ‘mere’ symptomatic change. After all, the deeper therapies were never ‘aimed’ at symptomatic relief, but rather at more enduring internal structural change. This point has always been a stumbling block in past comparative studies in that other treatment modalities have ‘settled for’ symptomatic change whereas the psychoanalytic psychotherapies have aimed higher – or deeper – depending on your perspective.
Finally, specific mention should be made of two chapters contributed by British authors on the psychoanalytically informed treatment of patients with borderline personality disorder – and indeed other severely disordered and even dangerous patients. Although these studies are less ‘immune’ from methodological criticism, they nevertheless report encouraging results. One of them quotes the Stevenson and Meares [3] studies – our own country's only attempt to address this very significant problem – to measure itself against.
In a public health service burdened by having to manage the so-called ‘serious mental illness’ conceptualized mainly as comprising schizophrenia and bipolar disorder, any psychiatry registrar will tell you that it is the borderline personality disorders and other severe personality disordered patients that confront them with the most serious management problems.
The studies reported here give guidance as to the most efficacious manner of managing these patients. Unfortunately, governments appear not to heed the need to invest suitable resources into providing services for this most difficult cohort of patients, despite the ‘revolving door’ nature of their modes of presentation.
One of the studies underlines the almost 10% mortality rate of the severe personality disorders – a figure in keepingwith my own experience in a Therapeutic Community Treatment Milieu in the mid-1970s: a serious problem in any branch of medicine.
Not everyone will need to read this book – but our profession and the government should take heed of its contents.
Let no one in this college ever again claim that there is no research into psychoanalytic psychotherapy.