What has happened to the practice of short term dynamic psychotherapy in Australia’s mental health services? A multidisciplinary training programme in Western Sydney

Abstract

Objective:

Short term psychodynamic psychotherapies have been markedly phased out of Australia’s mental health services. This paper aims to describe the successful introduction of a Conversational Model of Short Term Intensive Psychodynamic Psychotherapy into a public health service in an attempt to revive its practice.

Method:

A brief review of relevant papers in the Royal Australian & New Zealand College of Psychiatrists journals since 1980 gives a background to the decline of dynamic psychotherapy in Australia. The development of a Conversational Model of Short Term Intensive Psychodynamic Psychotherapy in the author’s private practice over 20 years, and its introduction into a hospital-based training programme are described.

Results:

A structured programme by scholarship has been offered yearly since 2011 to 10 multidisciplinary mental health clinicians of the Western Sydney Health District. Trainees see two patients from their own service. Over three years, 29 trainees have treated 57 patients with weekly supervision provided.

Conclusions:

The model has been easily learned. Trainees report a sense of re-invigoration, refinement of existing skills and acquisition of new skills. Resolution of problems in a significant number of patients is noted and improvement and satisfaction reported by others. A valuable service is provided and research is underway.

Keywords

conversational Model short term dynamic psychotherapy structured assessment active focused time-limited

There has been a decline in short term psychodynamic psychotherapy (STPP) in the Australian mental health system. A review of both journals of the Royal Australian & New Zealand College of Psychiatrists (RANZCP) since 1980 indicates that there has been some discussion, research and debate^1,2 about the benefits of both STPP and long term psychodynamic psychotherapy (LTPP). A restricted form of psychotherapy was recommended for somatoform disorders³ and the treatment of choice for neurotic/reactive depression.⁴ The Quality Assurance Projects of the RANZCP (1985-1991; too many to list due to limitation of space) recommended LTPP for several disorders, including personality disorders. With burgeoning research in cognitive behaviour therapy (CBT) and paucity of acceptable research in psychodynamic psychotherapy, CBT was favoured and dynamic psychotherapy marginalized. Publications thereafter dealt mostly with philosophical issues of LTPP and training, supporting ‘an apparent change in the nature of Psychiatry’.⁵ It was later declared that all recognized antidepressants, CBT and Interpersonal Therapy are equally effective in moderately severe depression and that emphasis on dynamic psychotherapy in the training of psychiatrists should be reduced (Quality Assurance Project 2004).⁶ Paradoxically, references to psychotherapy in the College journals have been passionate about the need for dynamic psychotherapy in psychiatry training.^7,8

CBT has responded quickly and appropriately to demands for a published and empirical evidence-base, that is, randomized controlled trials (RCTs); while STPP failed at the time to provide evidence that it is better than placebo.^9,10 A review¹¹ of STPP concluded that while 18 studies were identified with emerging evidence base that supports STPP as a treatment for depression, ‘methodological limitations continue to make firm conclusions about the effectiveness of STPP for specific disorders difficult to draw’. A systematic review and meta-analysis of 21 studies reporting the effects of STPP in patients with mood, anxiety, personality and somatic disorders found pre- to post-treatment effect sizes ranging from 0.84 (interpersonal problems) to 1.51 (depression), which gains were maintained at follow-up. Eight studies demonstrated cost effectiveness. The review concluded that within limitations of study methodologies, there is evidence to support the application of STPP across a broad range of populations – however, further rigorous and targeted research is warranted.¹²

Reasons for the failure of STPP research to reach acceptable standards may lie in the fact that patients used in RCTs are different from patients with complicating variables seen routinely; results obtained cannot reflect the realities of day-to-day clinical practice¹³ and of psychotherapy practice.¹⁴ Excessive beliefs in and weighting of the evidence emerging from RCTs deserve to be criticized, and an argument is put for adopting alternative approaches to evaluating the likely effectiveness of an antidepressant treatment.¹⁵

Method

Overview

Having trained in the Conversational Model (CM),¹⁶ an evidence-based¹⁷ model of LTPP, the author applied it to therapy with mother–infant/child dyads, adolescents and young adults in her private practice. Attempting to tailor the therapy to suit the patient meant shortening the duration while staying true to the principles of the CM. Reading the breadth of the literature and attending two intensive STPP training workshops overseas provided the necessary foundation for this work. The continuing experience of personal satisfaction and good outcomes with a number of patients within 10 to 30 sessions led to its introduction into a training programme at the psychotherapy unit, where discussions had been underway for some time to start a training programme in a short version of the CM.

Training

Western Sydney Health offered 10 scholarships to interested clinicians to undertake the training alongside the LTPP training.¹⁸ Trainees are accepted through a selection process to the half-day-a-week, 28-week training programme, consisting of didactic and clinical components. Introductory lectures to the CM are common to both groups at commencement, after which separate didactic seminars on STPP-CM are conducted and audio-recorded patient sessions are supervised in groups.

Characteristics of patients

Traditionally, strict selection criteria are used for patients receiving STIPP¹⁹ (derived from earlier models of STPP) but in view of today’s mental health services where patients with wide-ranging psychopathologies present, these criteria would permit only a fraction of patients to receive treatment. Patients range from those with depression and anxiety, deliberate self-harm, suicidal ideation, unresolved grief, relationship and/or work difficulties, recovery from major mental illness to alcohol and/or drug abuse, domestic violence, personality disorders, impulse control disorders, phobias and eating disorders. In view of co-morbidity, particular assessment procedures help the therapist decide whether any additional measures are required in order to ethically and effectively work with such patients in STIPP-CM. The therapist decides on suitability and a focus of work is collaboratively chosen, as in the following illustration:

Cate age 54 presented with a history of depression, shop-lifting, unspecified phobias and binge drinking. Cate was assessed to be suitable for STIPPCM. ‘Yet, she had so many problems,’ thought her clinician. They agreed to work on her shop-lifting, as Cate was worried about her reputation if she were caught. She stopped shop-lifting after 18 sessions. Further work helped consolidate gains she had made and binge-drinking was the next focus. Cate had been on antidepressants for many years – this was successfully reduced. She had not shop-lifted during the ensuing 6 months.

A history of trauma is not an absolute contraindication; co-morbidity is frequent, as in the following example of a patient seen by the second author:

Trixie aged 49 years with a diagnosis of Borderline Personality Disorder (BPD) was on a wait-list for long term therapy, and in the meantime was repeatedly presenting to the emergency room with serious self-harming behaviour. Her limbs were covered with scars – old and recent, she had a history of early abuse and at every presentation she was stitched up and allowed to return home. Hospital staff found her to be avoidant and difficult to engage. She stopped self-harming by the 5th session and completed 25 sessions during which time she did not re-present to hospital. I had started STIPP-CM training and contracted to see her for 25 sessions. By the 4th session we had begun to establish a therapeutic relationship; she volunteered that she had never been heard, leave alone being understood by anyone before. The combination of seminars and supervision provided for me scaffolding in which I began to learn the principles of STIPP-CM and apply them to what I saw was happening with my patient, and thereby help her with her problems. I had never known these principles before, in spite of having completed several training programs. As we neared the ending, Trixie who was quite conscious that we had four sessions left, complained of feeling unwell with back pain which interrupted her sleep. We looked at the possibility that her pain and sleeplessness could be associated with her feelings around the end of our therapy. This intervention brought up for her a series of painful separations in her life. Talking about them, Trixie began to feel better and reported improvement in her pain. She maintained her sense of wellness 6 months later – she had not self-harmed, she was in a relationship and had taken up a hobby outside her usual work.

Questionnaires

The process is explained and patients are required to complete several pre and post questionnaires. Informed consent is obtained to audio-record sessions for supervision, examination, presentations and research. Anonymity and confidentiality are assured. Therapist adherence to the model is being tested by STIPP-CM Adherence Scales. Results of questionnaires will help assess change in presenting problems and in social and relational functioning.

The STIPP-CM model

STIPP-CM, derived from earlier models of STPP,^19,20 is an active, time-limited, structured and focused psychotherapy that uses the principles of the CM. Attention is paid to the formation of a good therapeutic relationship, though this is not explicitly discussed with the patient. Structure is flexible, moving through three mutually informed but arbitrary stages that help the therapist and patient to orient themselves to the tasks at hand and what is to be accomplished.

Early stage: assessment and formulation (1–3 sessions)

The therapist is required to assess the patient’s problems and mental state on several specific parameters and decide on suitability, bearing in mind such contraindications as substance dependence, active psychotic illness, extreme self-destructive behaviour, active suicidal ideation, severe personality disorder and serious major depression. The clinical data generated is a joint exercise, a summary of which is shared with the patient and forms the basis for treatment planning. Following discussion of this formulation, and agreement by the patient, the rationale of therapy and a mutually arrived at focus of work is decided upon; a contract is made with decisions around the frame and the end date of therapy is set.

Middle stage (sessions 4–20)

While maintaining the focus, in-session facilitation and elaboration of affective experience encourages deeper emotional processing. This leads to identification of habitual ways of coping and relating, which helps the patient to see connections between symptoms and relational themes both current and past. Errors on the part of the therapist are corrected, and conditions are created in which the patient can express and resolve emotional states in the therapeutic relationship.

End stage (sessions 21–25)

Presenting problems are reviewed, the patient’s reactions to ending are explored, progress acknowledged, difficulties validated, future plans discussed and a summary of the therapeutic work done, in the form of a ‘goodbye’ letter, is given to the patient in the penultimate session. Patients are assured that gains become more evident after the therapy is over; however, in the event of problems recurring, a top-up is provided. A few patients may be referred for LTPP.

Conclusions

Outcomes at the end of therapy have been encouraging so far. This approach provides a way of helping all but the most seriously disturbed patients, many of whom have been unresponsive or have refused CBT and other treatments. Therapists are offered a structured alternative model of working, used in crisis situations between one and three sessions and in short-term therapy to a maximum of 25 sessions. STPP is efficacious¹⁰ and cost effective¹² and can be delivered in a few sessions; but the research, until now, is said to be of an unacceptable standard. Is it not time to reconsider?

Footnotes

Acknowledgements

I wish to thank Emeritus Professor Russell Meares for his encouragement, especially around the development of a manual, Anthony Korner, current Head of the Complex Trauma Unit, whose timely initiative resulted in the introduction of this training programme, and the team who make this work possible.

Disclosures

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

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