Effectiveness and cost effectiveness of Davanloo's intensive short-term dynamic psychotherapy: does unlocking the unconscious make a difference?

More than 20 years ago Habib Davanloo coined the term unlocking of the unconscious to describe how the psychodynamic concept of the human unconscious can become accessible using the technique of Intensive Short-Term Dynamic Psychotherapy (ISTDP). According to Davanloo, the possibility that unconscious material will be revealed is greatly increased when therapeutic efforts promote dominance of the unconscious therapeutic alliance over unconscious resistance. When these ingredients are present there is a psychic shift that allows unacceptable painful feelings to come to the surface. Toward adding further empirical support for the concept, in this article we compare outcomes between patients who experienced one or more major unlocking of the unconscious (N = 57) to those who did not experience major unlocking (N = 32) during ISTDP treatment. Significant and widespread differences were seen between these two groups, those with major unlocking had greater symptom reduction, interpersonal gains, and cost reduction for treatment. The relevance of this to clinical practice and healthcare utilization will be discussed.

The cost-effectiveness of short-term psychodynamic psychotherapy and solution-focused therapy in the treatment of depressive and anxiety disorders during a one-year follow-up.

BACKGROUND: Mood and anxiety disorders are characterized by a high and increasing prevalence, they cause a lot of costs and human suffering and there are many treatment options with differing costs. The benefits of identifying the treatments with the most favourable cost-effectiveness ratios can be substantial. However, the number of randomized trials where psychological treatments are compared with each other and where economic aspects, too, are taken into account is still relatively small. AIM: To compare the cost-effectiveness of two short-term psychotherapies in the treatment of depressive and anxiety disorders during a one-year follow-up. METHODS: In the Helsinki Psychotherapy Study, 198 patients, who were 20--45 years of age and met DSM-IV criteria for anxiety or mood disorder, were randomized to short-term psychodynamic psychotherapy (SPP) or solution-focused therapy (SFT). Psychiatric symptoms were assessed at baseline and 4 times during the one-year follow-up from the start of therapy using the Beck Depression Inventory and the Symptom Check List Anxiety Scale, and 2 times using the Hamilton Depression Rating Scales and Hamilton Anxiety Rating Scales. Both direct costs (therapy sessions, outpatient visits, medication, inpatient care) and indirect costs (production losses due to work absenteeism, value of neglected household work, lost leisure time and unpaid help received) due to mental disorders were measured. Mean total costs were compared and incremental cost-effectiveness ratios analyzed. RESULTS: According to all 4 psychiatric outcome measures, symptoms of depression and anxiety were reduced statistically significantly in both therapy groups during the one-year follow-up. The relative changes were about the same size according to all four outcome measures. In both groups the reductions took place mainly in the first half of the follow-up. The reductions were somewhat greater with SPP, but the differences between the two groups were small and not statistically significant at any measurement point. The mean total direct costs were 1791 euros in the SPP group, being 346 euros (16%) lower than those of the SFT group, but this difference was not statistically significant either. Also the incremental cost-effectiveness ratio points calculated by 500 bootstrap iterations favoured SPP. The total indirect costs in the SPP group were, in contrast to direct costs, higher than those in the SFT group, but, again, the difference was not statistically significant. LIMITATIONS: The generalization of our results may be weakened by the fact that the patients included in our study were relatively young, and the follow-up period was restricted to one year. IMPLICATIONS: This study suggests that there are no notable differences in cost-effectiveness between SPP and SFT. If one were obliged to choose between these two therapies our results would support the choice of SPP. However, more research with extensive data about both costs and effectiveness, compiled over a period longer than one year, are needed before any firm conclusions can be drawn about the cost-effectiveness of the two therapies compared in this study.

Dynamic deconstructive psychotherapy versus optimized community care for borderline personality disorder co-occurring with alcohol use disorders: a 30-month follow-up.

Patients having co-occurring borderline personality disorder and alcohol use disorders represent a common, but particularly severe and refractory subgroup. An individual, time-limited treatment, dynamic deconstructive psychotherapy (DDP), has been shown to be effective for this subgroup, but long-term outcomes are not known. Participants were recruited from a sample of 30 patients enrolled in a 12-month randomized controlled trial of DDP versus optimized community care (OCC). Outcomes were assessed after an additional 18 months of naturalistic follow-up. DDP participants received an equivalent amount of individual treatment and less group therapy than those receiving OCC, but demonstrated large, sustained treatment effects over a broad range of outcomes and achieved significantly greater improvement in core BPD symptoms, depression, parasuicide, and recreational drug use over the 30-month study. These results suggest that DDP is a cost-effective treatment that can lead to broad and sustained improvement for the dually diagnosed subgroup.

A cost-utility analysis of psychoanalysis versus psychoanalytic psychotherapy.

OBJECTIVES: Despite the considerable and growing body of research about the clinical effectiveness of long-term psychoanalytic treatment, relatively little attention has been paid to economic evaluations, particularly with reference to the broader range of societal effects. In this cost-utility study, we examined the incremental cost-effectiveness ratio (ICER) of psychoanalysis versus psychoanalytic psychotherapy. METHODS: Incremental costs and effects were estimated by means of cross-sectional measurements in a cohort design (psychoanalysis, n = 78; psychoanalytic psychotherapy, n = 104). Quality-adjusted life-years (QALYs) were estimated for each treatment strategy using the SF-6D. Total costs were calculated from a societal perspective (treatment costs plus other societal costs) and discounted at 4 percent. Psychoanalysis was more costly than psychoanalytic psychotherapy, but also more effective from a health-related quality of life perspective. The ICER--that is, the extra costs to gain one additional QALY by delivering psychoanalysis instead of psychoanalytic psychotherapy--was estimated at 52,384 euros per QALY gained. CONCLUSIONS: Our findings show that the cost-utility ratio of psychoanalysis relative to psychoanalytic psychotherapy is within an acceptable range. More research is needed to find out whether cost-utility ratios vary with different types of patients. We also encourage cost-utility analyses comparing psychoanalytic treatment to other forms of (long-term) treatment.

Payment as perverse defense.

A case is discussed in which the patient's management of aspects of the payment process is seen as a focal point in a perverse defensive structure operating in the treatment. Detailed process material is examined with attention to transference and countertransference components of this defensive process. Recent literature on perverse thought and defense is reviewed in order to understand this case in the context of current thinking, to generate new ideas about the nature of perverse defenses, and to consider the potentially special role that money may play in the operation of such defenses in psychoanalysis.

Succession and survival in psychotherapy organizations.

This paper examines the world of psychotherapy by applying a systemic and psychodynamic understanding of the family business as a way of understanding the dilemmas and challenges of leadership succession. Oedipal factors are explored as an important theme within the succession process. This exploration is set within the context of what function psychotherapy has performed in society over the last thirty years. The hypothesis is that the first generation of leaders aimed to provide containment for the individual citizen at a time of failed dependency in society. The suggestion is that this gave way to the primary task for the second generation, which has been to focus on the therapist in training. The challenge for the third generation is to develop a meaningful role for psychotherapy today and to ensure survival at a time when other shorter therapies such as CBT are gaining ascendancy over longer term psychoanalytic psychotherapy.

Costs and benefits of long-term psychoanalytic therapy: changes in health care use and work impairment.

OBJECTIVE: systematic review regarding the effectiveness of long-term psychoanalytic therapy (LPT) on health care use and work impairment in adult outpatients. METHOD: a systematic search for studies published between 1970 and 2005. Calculation of the weighted mean changes between pretreatment and treatment termination, and between pretreatment and follow-up. The findings are translated into financial terms, and the costs of treatment are balanced against the financial gains. RESULTS: seven studies (n = 861) met all the inclusion and none of the exclusion criteria. The mean cost of LPT per patient was 20,900 Euro. During the year preceding treatment termination and the year preceding mean follow-up (2.9 years), the average reduction was 85% and 59%, respectively, in the number of hospital days; 54% and 56%, respectively, in the number of medical consultations; 70% and 19%, respectively, in the number of medication users, and 61% and 67% in days of sick leave. Health care use and sick-leave costs fell by an average of 5,584 Euro , or 66%, between the year preceding the start of psychotherapy and the year preceding treatment termination. At mean follow-up (2.9 years) these costs reductions were still apparent, as the reduction was 5,372 Euro, or 64%, in the year preceding follow-up. The break-even point for benefits and treatment costs was approximately three years after treatment termination. The reduction in work impairment appears to be the main factor (65% to 75%) in these positive results. CONCLUSIONS: our data suggest that LPT substantially reduces health care use and sick leave. The benefits seem to endure for years after termination and reach the point of counterbalancing the costs of treatment approximately three years after treatment termination.

Intensive psychotherapy of a borderline patient.

A detailed case report of the long-term intensive psychotherapy of a borderline patient illustrates my approach to such patients. It also raises questions about the value of interpretations in the early phases of therapy of such patients, regardless of which conflicting theories are chosen as the basis of these interpretations. Stress is placed on the value of empathic attunement to the patient, staying with the patient through the many vicissitudes of long-term treatment, and the developmental use the patient made of a long treatment, reliving certain phases of development in the transference. Acquisition of internalized controls may need to occur in this way before the patient is ready to utilize interpretations. Also illustrated are the difficulties in convincing insurance companies and other third parties to support long-term psychotherapy and the effects of such intensive interaction over the years on the psychotherapist.

Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care.

OBJECTIVE: The authors assessed health care costs associated with psychoanalytically oriented partial hospital treatment for borderline personality disorder compared with treatment as usual within general psychiatric services. METHOD: Health care utilization of all borderline personality disorder patients who participated in a previous trial of partial hospital treatment compared with treatment as usual was assessed by using information from case notes and service providers. Costs were compared for the 6 months before treatment, 18 months of treatment, and an 18-month follow-up period. RESULTS: There were no cost differences between the groups during pretreatment or treatment. Costs of partial hospital treatment were offset by less psychiatric inpatient care and reduced emergency room treatment. The trend for costs to decrease in the partial hospitalization group during the follow-up period was not apparent in the treatment-as-usual group. CONCLUSIONS: Specialist partial hospital treatment for borderline personality disorder is no more expensive than treatment as usual and shows considerable cost savings after treatment.

Cost-benefit analysis of psychosomatic therapy in asthma.

The effectiveness of psychosomatic therapy for asthma patients is difficult to prove. We tried to solve this problem in a new way by means of a cost-benefit analysis. To draw up such an analysis, we selected 22 patients capable of working out of a total of 57 patients with asthma bronchiale at the Heidelberg Medical Hospital, who were interested in participating for one year in a psychosomatic coping group therapy. These 22 patients were divided into two groups. The distribution of the relevant individual parameters in both groups was similar. We subjected the patients to three medical and psychodiagnostic examinations: one before treatment was started, a second after the first year of treatment and a third one and a half years later. Additional data were gathered from health insurance organisations and General Practitioners. Despite the bad prognoses of our patients, those treated, when compared to the untreated patients, had a significant reduction in the number of working days lost and a considerable decrease in the number of working days hospitalized. The savings resulting from these reductions were compared with the sum expended for group therapy; we found a cost-benefit ratio of 1:5. These results indicate that a cost-benefit analysis may be very helpful in evaluating the effectiveness of some psychosomatic treatment techniques. Moreover, coping group therapy completes the medical standard therapy of patients with bronchial asthma and is thus a means of reducing the high medical treatment costs of asthma patients.

Are psychoanalytic billing practices ethical?

The changing climate of "health care reform" and increased third-party intrusion into psychotherapy are raising challenges over the ethics of traditional psychoanalytic practices such as billing for missed sessions. The practice of billing for missed sessions is an integral part of some analytic psychotherapies and forms the basis of the field of operation of many therapies. When used in this way, the billing practices are unique in medicine in that only these therapies use billing as a part of treatment. This practice is used for a variety of practical reasons but especially to emphasize to patients that the therapy occurs in their internal lives and addresses the symbols they use in organizing their world view. The symbolic use of a time commitment and the obligation to pay for that commitment are necessary so as not to present the patient with a contaminated field of operation. In this way the practice is similar to many other areas of medicine, such as surgeries that are viewed as global procedures whose billing allows for time that is not actually spent in contact with patients. This paper discusses the clinical rationale for the ability to bill for missed sessions and its ethics in terms of the newer language of utilization review. By laying down the principle of billing as a practice parameter for an open-ended bundled service that is billed globally the author translates the practice into more modern utilization-review terminology.

Transference and countertransference interpretations: harmful or helpful in short-term dynamic therapy?

Finding effective and economical interventions in brief therapy has become a challenge for therapists of all orientations needing to make noticeable progress within a short period and to achieve positive, measurable outcomes. In this paper three theoretical positions and the empirical data purporting to support them were examined: (1) not using either transference or countertransference interpretations; (2) using transference but not countertransference interpretations; and (3) relying heavily on both kinds of interpretations. Though limited research prevents firm conclusions, findings support infrequent, careful, and cautious usage of transference and countertransference interpretations, including crafting them to meet specific patient characteristics and reflect presenting problems. If appropriately used, both interpretations can affect outcome by contributing to alliance building, perseverance in therapy, and goal attainment. If inappropriately used, however, both interpretations can cause harm, even premature termination. Finally, research findings do not support the theoretical position that positive outcome depends on transference and countertransference interpretations.

Iatrogenic factors in "managed" psychotherapy.

The clinical implications of the "case-manager" system are explored through a detailed case presentation. It is demonstrated that the introduction of a third person into the therapeutic relationship compromises the therapeutic alliance and the transference. Under such conditions psychotherapy is impossible.

Referral to psychoanalytic candidates: a special problem in technique.

The technique of referral has been given scant attention in the analytic literature. Yet the method of referral, particularly to analytic candidates, can have a significant impact on the subsequent treatment. Listening to detailed case presentations by candidates over a four-year period in a course on selection of patients, it became apparent to me that when analysts referred patients to candidates they almost always avoided telling the patient that the analyst was in training. The reasons for the evasion and the consequences of it are explored in all three parties: the referring analyst, the patient, and the candidate. Clinical material from typical situations is presented to illustrate how evasions and distortions by the referring analyst can have a negative impact on the patient, the candidate, and the analysis. The suggestion is made that the referring analyst be open about the candidate's status, particularly when the patient is being seen at a reduced fee. As with any other situation, candor enhances the chances of success of the referral and subsequent analysis.

Assessment of suitability for low-fee control psychoanalysis: some theoretical and technical considerations.

In the assessment of suitability for low-fee control analysis, various factors may interfere with successful referral, evaluation, and disposition. Variables within the referring analyst, patient, candidate, and supervisor are examined in their interaction with the circumstances of the assessment enterprise. Issues of competence, self-esteem, and oedipal rivalry, as well as guilt feelings, concerns about rejection, and other conflicts may be mobilized and may prevent a successful outcome. Clinical data from three assessments are presented and discussed. The concept of an assessment process, analogous to the psychoanalytic process, is proposed. In this process, manifestations of the patient's intrapsychic life and indicators of potential transferences emerge in the context of the analysis of the patient's reactions to the assessment. Potential sources of interference with the assessment process are identified, and measures to avoid them are suggested.

The FACE Recording and Measurement System: a scientific approach to person-based information.

Modern health care systems increasingly require clinicians to provide person-based information for purposes of outcomes and resource management. These demands have traditionally been met by the establishment of parallel data collection activities that can place an excessive burden on both clinicians and the organization. The author describes an approach to information that integrates clinical recording with measurement in a manner that both provides the required information for management purposes and supports day-to-day clinical activity. The Functional Analysis of Care Environments (FACE) Recording and Measurement System integrates clinical, management, and regulatory requirements. In so doing, it also has the potential to provide a basis for effectiveness research and protocol development that can both support and enhance clinical knowledge and practice.

Process and outcome in mental health care delivery: a model approach to treatment evaluation.

In recent years, there has been a strong movement toward "evidence-based medicine," which has significantly affected approaches to the delivery of mental health care. The author highlights the cultural and socioeconomic context in which this trend has emerged. He also notes the resulting controversy over the emphasis on randomized controlled trials (RCTs). Although he does not reject the important role of such trials, he reviews some of their limitations and offers a rationale for the equally important role of naturalistic outcome studies. He concludes by introducing subsequent articles in the journal issue that describe a computerized, online approach for evaluating the effectiveness of mental health care delivery. This system, originally developed in the United Kingdom, has been adapted for use by The Menninger Clinic.

Measuring disability and outcomes in routine practice with the FACE Core Assessment.

The authors describe the results of an outcome study of 87 psychiatric inpatients and outpatients using a generic assessment and outcome measurement tool, the FACE Core Assessment. The results suggest that the multiaxial structure of the assessment tool has the potential to be used for the routine measurement of clinical outcomes as well as for multidisciplinary assessment.

Some technical and theoretical considerations regarding the missed session.

Although Freud (1913b) originally proposed the 'principle of leasing a definite hour', there are many proponents of a more 'lenient' fee policy. The author critically examines some of the arguments put forward by the latter writers and argues that the missed session risks degrading into a 'missing' session if a financial marker does not remain in the patient's vacated place. The conflict mobilized in both partners to the therapeutic relationship by the missed session is best left open for analytic exploration rather than solved by a 'rational' and 'flexible' fee arrangement. The author suggests ways of theorizing, and eventually interpreting, the 'breach' in the relationship in terms of the absent, decentred subject, the Desire of the Other, the inherent contingency of our most primitive identifications, and the ineluctable violence and alienation of human interdependency. The 'rule of indenture' is seen in closer affinity to these basic contradictions than the more gracious 'gentlemen's agreement'.

Psychoanalytic technique and the creation of analysands: on beginning analysis with patients who are reluctant to pay the analyst's fee.

This paper discusses prospective analysands who are able but reluctant to pay analysts' fees. The author presents analytic data in which analysts decided to gratify their reluctant analysands by reducing their fees in order to facilitate the subsequent analysis of their reluctance. These examples are employed to discuss the general question of fee reduction.