The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
The Case for Long-Term Psychodynamic Psychotherapy:
A response to the
Derbyshire County Primary Care Trust
I have written this paper in response to the Derbyshire County PCT’s consultation on Tier 4 Psychological
Therapies
Services. It is in four parts: Firstly, a personal introduction; secondly, a critique of the evidence base presented by the PCT in the
form of a literature review; thirdly, a personal
review of more recent empirical research in the field of long-term psychodynamic psychotherapy and, lastly, a series of comments on the implications of the above for psychodynamic psychotherapy services in Derbyshire.
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
Part One
A Personal
Introduction
I am Dr David Smith (G.M.C. No 2304816) a consultant psychiatrist and specialist in
psychological therapies who retired from working in the NHS mental health services in Derby and Derbyshire at the end of August this year. I have been a member of the Royal College of Psychiatrists since 1981 and was appointed as consultant in 1985.
The
consultant post required
me
to provide therapy for
patients in a variety of different treatment modalities including psychodynamic, cognitive - behavioural and
family systems therapies and to organise and provide training in these therapies for health services staff and, in particular, for medical doctors at all levels of training.
In my
role
as consultant I provided
medical leadership
to
the specialist teams
in cognitive – behavioural and psychodynamic psychotherapy that I worked with in the
mental
health
services
in
Derby. I
have been a long standing proponent of an evidence-based approach to clinical practice and
to
psychological therapies
in
particular.
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
Part Two
A Critique of the Presented
Evidence
In this part I offer
a
critique
of
the evidence
base for
psychological therapy as described by the PCT in its documents posted on its website as background to its
2011 draft service specification for
Tier 4 Psychological Therapies Services.
The principal paper outlining the evidence review is a paper authored by Vicki Price, consultant in public
health at NHS Derbyshire
County. It is headed “Psychological
Therapy Literature Reviews”. I have marked it as Document ‘A’ for the purpose of
clarity. Embedded in the text are a number of further documents which I will turn to first.
Document A
The first embedded
document is headed “Literature Review of Psychological
Therapies”. The authorship of the paper is not given nor are their qualifications.
I
have marked the
document ‘B’ again for clarity and at points in the text put a number
to indicate where I want to
make
a particular observation.
Document B
Document B, Point 1: Psychological therapies are indeed a complex range of therapy practices but to assume that this
leads to “confusion” about effectiveness is surely mistaken. There are
uncertainties in
the field, of course, and competing claims but as much
would
be true of many areas
of medical practice
and the debate is all part of
an entirely proper process of developing a knowledge base. In some measure difficulty in
interpretation arises due to the nature of the question put - “Are psychological therapies effective?” Consider, for instance, how difficult it might be to answer the
question -
“Is surgery effective?”
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
Document B, Point 2: It is not the case that all studies contain a highly selected
group of patients. Good quality studies of long-term psychodynamic psychotherapy (LTPP) are conducted with patients in “real-life” clinical settings (e.g. Bateman and
Fonagy.
American Journal of Psychiatry. Winter 2010. 8;55-65) and may therefore be regarded
as
testing both
the
efficacy and
effectiveness of
the treatment. Furthermore, heterogeneous
clinical populations
are described in a recent meta-
analytic review of LTPP (Leichsenring and Rabung. Journal of the American Medical
Association.2008.
300
(13); 1551-1565).
Document B, Point 3: I am not aware of any high quality
studies of LTPP in which the
desired outcome was containment or maintenance.
The suggestion
that it may not
be
appropriate to consider studies which measure benefit in terms of improvement in client behaviour is, frankly, absurd in the context of a review
of psychological
treatments where patients’ behavioural problems, for instance the frequency of their
deliberate self harm episodes, are major issues in their overall
disturbance.
Document B, Point 4: Publication bias appears to be a significant problem in relation
to cognitive-behavioural
therapy (CBT) research in depression. In
the paper referenced (P. Cuijpers et al. British Journal of Psychiatry. March 2010. 196;173-178)
no
studies of psychodynamic psychotherapy were included in the data set and it was
noted that studies in one treatment modality,
interpersonal psychotherapy, were not
found to be subject to this
bias. It is therefore not reasonable to assume that research in other conditions
is subject to publication bias, at least not for all therapy modalities. Leichsenring and Rabung (British Journal of Psychiatry. 2011. 199; 15-22)
in their meta-analysis of LTPP studies take considerable care to assess the
risk of publication
bias in their
data and found
no indication of
this.
Document B –
Point 5: In their meta-analytic
review of LTPP, Leichsenring and
Rabung (British Journal of Psychiatry. 2011. 199; 15-22) do in fact assess the effect of
this treatment in a generic sense.
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
Document B – Point 6: In a study entitled “Differences in clinical characteristics between patients
assessed
for
NHS specialist
psychotherapy and
primary care counselling”
M. Chiesa et al (Psychology and Psychotherapy. 2007. Dec. 80; Pt4; 591-
603) found that patients referred for specialist psychotherapy were more dysfunctional than those referred for primary care counselling, including presenting
with
more psychotic symptoms and higher risk of self harm.
Document B – Point 7:
In the NICE Guidelines for Eating Disorders, CG9 Jan 2004, in section 6.2.3.3 “Evidence
statement” it is noted that there is limited
evidence that both family
interactions and focal psychoanalytic
psychotherapy given at tertiary referral centres are superior
to treatment as usual in terms of proportion of people recovered by end of treatment. In section 6.2.9 “Clinical Practice Recommendations” the guidelines note under sub-section 6.2.9.1 that “Therapies to be
considered
for psychological
treatment
of
anorexia
nervosa include cognitive analytic therapy (CAT), cognitive
behavioural therapy (CBT), interpersonal therapy
(IPT) , focal psychodynamic therapy and family interventions focussed explicitly on
eating disorders”. Sub section 6.2.9.2
states that “Patient and where appropriate
carer preference, should
be taken
into account in deciding which
psychological treatment is offered”. Focal psychoanalytic or psychodynamic psychotherapy is a form of psychodynamic therapy that continues for at least a year. In the randomised controlled trial that the recommendation
for this therapy was based upon this was
indeed the case (C. Dare et al. British Journal of Psychiatry. 2001. 178; 216-221). A year
in therapy would be regarded as at least of moderate length, longer than what would usually
be
seen as the parameter of short term work.
It is unaccountable as to why the author of the “Literature review of Psychological
Therapies” omitted to mention focal analytic therapy in the list given of
recommended therapies.
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
Document B – Point 8 – In the section on personality disorder no mention is made of
the
NICE Guidelines for Borderline Personality Disorder, NICE CG 78.
In Chapter 5 of
this guideline there is an exploration of psychological and psychosocial treatments in
the
management of the disorder. In sub-section 5.10 the guideline development
group
note that
“........... the
state
of
knowledge
about the
current
treatments
available is in a development phase
rather than one of consolidation. Conclusions are, therefore, provisional and
more
and
better designed studies need to be
undertaken before stronger recommendations
can be made.
There is some evidence
that psychological
therapy
programmes,
specifically DBT (Dialectical
Behaviour
Therapy) and MBT (Mentalisation Based Therapy)
with partial hospitalisation, are
effective
in
reducing
suicide attempts
and self harm, anger,
aggression
and depression.
MBT with partial
hospitalisation reduces anxiety and overall borderline
personality disorder
symptomatology and improves employment
and general functioning.”
The group rounds off its overall clinical summary in sub-section 5.10 by stating that “Referrals for
psychological treatment should take into
account
service
user preference and where practicable offer a choice of approach”
Mentalisation based theory (MBT) is a form of long-term psychodynamic psychotherapy as the clinicians, Professors Bateman and Fonagy, who developed the approach, clearly state (Bateman and Fonagy.
American Journal of Psychiatry. 2010.
8; 55-65)
In an exposition of these guidelines to
general practioner colleagues the chair of the
guidelines development group, Professor Peter Tyrer,
notes on page 5 of the
included
document “Borderline
Personality Disorders Requires a Team Based approach” that,
“For
severe forms of borderline personality disorder a structured long-term (at least six months but usually longer) form
of management such as .... mentalisation – based treatment, ..... is given.” Later in the lecture Professor Tyrer reinforces the NICE
guideline that all
PCTs should have a personality disorder
service.
Borderline
Personality Disorder
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
Again it is unaccountable as to why the author of the review included in the PCT
evidence base has omitted
discussion of NICE guidelines for borderline personality
disorder with
their recommendations
for this form of LTPP.
Document B – Point
9: A more
up to date
systematic
review of psychological
treatments for personality disorder is available (R.Verheul et al. International Review
of
Psychiatry. 2007. Vol 19, 1; 25-38). These
authors conclude that “...... various
psychotherapeutic treatments have proven to be efficacious with respect to reducing symptomatology
and personality
pathology, and
improving
social
functioning in patients with cluster A, B, C and not-otherwise-specified personality
disorder. This is especially true for cognitive
behaviourally or psychodynamically oriented outpatient
individual psychotherapies.”
Document B – Point 10: The NICE Guidelines In The Treatment And Management Of
Depression (NICE CG 90. 2010) state another recommendation 8.11.3.4
“For people
with
depression who decline an antidepressant, CBT, IPT, behavioural activation and behavioural couples’ therapy consider short-term psychodynamic psychotherapy for
people with
mild to
moderate
depression.” In
section 8.12.1.1
the guidelines
development group recommends that
the efficacy
of
short-term psychodynamic psychotherapy compared
with
CBT and antidepressants
in
the treatment of moderate to severe depression should
be further researched.
It can taken
from these
recommendations
and particularly
the latter
that
the
question of the efficacy of
psychodynamic psychotherapy in depression of varying
degrees of severity is at least an open one, and of course, worthy of further research.
A major research study of the efficacy of long term analytic psychotherapy in chronic
depression is currently being undertaken
by
the Tavistock Clinic in
London.
Document B – Point 11: However, Leichsenring and Rabung’s paper (British Journal of Psychiatry 2011. 199;
15-22) describes a high
quality meta-analytic
study of controlled trials of LTPP.
Document B – Point 12: As noted in point 4 such a conclusion may be drawn only for
CBT.
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
Document B - Point
13:
To
conclude that
the evidence
base for
psychological
therapies is equivocal is, I think, a mistaken
generalisation.
A generally received view is that a range of therapies across a range of disorders are of moderate to good effect. (“Psychological Therapies in Psychiatry and Primary
Care.” June 2008 College
Report 151. Royal College of General Practitioners and Royal College of Psychiatrists.)
Document B – Point 14: A view that treatments should
be
made available where only the “most robust” evidence exists is contentious to say the least and is one that would not, I venture to suggest, receive widespread public support.
Across medical practice
generally there
is
uncertainty about
many
established
and provided
practices (El Dib RP et al. J.Eval. Clin. Pract. August 2007. 13. (4); 689-92. “Mapping
the
Cochrane evidence for
decision making in health care”).
This
review of psychological
therapies (document ‘B’)
is certainly open to criticism, as
noted above. It seems
often to be unreasonably sceptical
in tone and contains judgements, for
instance about what
the author finds “convincing”, that
have no reference points. There are some surprising omissions in the appraisal of NICE
guidelines. The paper has
not noted the best available evidence for
the
psychological therapy for personality disorder
in particular, a notable failing in the paper given the
high prevalence of
patients with such a diagnosis in the population
of service uses
in secondary mental health services and specialist psychotherapy services
A second
embedded document
is
headed
“Knowledge
Services
NHS.
Literature Search Results. Title: Long-term
psychodynamic therapy in
mental health conditions”. Again no indication is given of the author(s) or their qualifications.
I
have marked this document ‘C’ for the sake of clarity and have numbered
alongside the text at various points when I
have a comment to
make.
Document C
Document C – Point 1: A Cochrane review of psychological therapies for people with
borderline
personality disorder (C.A.Binks, et al. Cochrane Database of Systematic Reviews, 2006. Issue 4) notes that both dialectical behaviour therapy and
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
psychoanalytically orientated day hospital therapy (a form of LTPP) may be helpful
for
patients with personality
disorder but that further studies are required. Further
studies have been published (see Section
Three of this paper) which continue to indicate the helpfulness
of psychodynamic psychotherapy.
Document C – Point 2: Leichsenring and Rabung take the view that the clinically
heterogeneous set of studies included in this meta-analysis increases the
generaliseability
of the results. In everyday clinical practice therapy services are dealing with a mixed population of patients.
In a more recent meta-analysis these authors (Leichsenring and Rabung, British Journal of Psychiatrists. 2011. 199; 15-22)
address further the
sort of
concerns raised
by the
York University CRD in their
appraisal of this 2008 study, but in any case the CRD’s concerns should not nullify the study’s
findings.
Document C – Point 3: The conclusion
from this 2003 review that psychological therapies are helpful for people
with personality disorders is
preliminary but it should
nonetheless stand and can be dismissed only if negated
by later research. In fact, studies
reporting
in
the years following this
review
are
generally
positive
and continue to support the conclusion of effectiveness. (eg. Vinnars et al. American
Journal of Psychiatry. October
2005.
162;
1933-1940.)
Document C – Point 4: But there are many mentions of psychodynamic
psychotherapy in NICE guidelines. As
noted in the
critique
of
paper
‘B’
above
guidelines on eating disorders, depression and
borderline personality disorders
discuss and
recommend
psychodynamic
psychotherapy. Furthermore
in
NICE
Guideline CG82 on Schizophrenia in section 8, sub-section 8. 8.7.1. it is noted that
“Healthcare professionals may consider using psychoanalytical and psychodynamic principles to help them understand the experiences of people with schizophrenia and
their interpersonal relationships.”
Document C – Point 5: These guidelines on post-traumatic stress disorder, CG 26,
clarify in sub section 2.3.6.1 that they do not apply to complex trauma cases such as
might arise from childhood sexual
abuse and where
there are enduring personality
changes. In the clinical population
of service uses receiving LTPP there are many
people who have
experienced
significant early life
trauma
with negative and
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
enduring impacts on their personality development. Earlier in the same guidelines document NICE recognises some of the limitations of guidelines generally. In section
1.1.2 it is stated
that “They
(guidelines)
are
not a substitute for
professional
knowledge and clinical judgement.” Later adding “However, there will always be
some patients for whom clinical guidelines
recommendations are not appropriate and
situations
in
which the
recommendations are not
readily
applicable. This
guideline does not, therefore, override the individual responsibility
of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with
the patient and/or
carer.” Importantly in the
same section
the guidelines
development group note
that
“The absence of empirical evidence for the
effectiveness of a particular intervention is
not the
same as evidence of ineffectiveness.”
Many service users come to psychotherapy wanting to talk through and hence try to
come to terms with major early life trauma. Many such people have some features
at least, of the ICD 10 personality disorder diagnosis, F62.0 “Enduring personality change after catastrophic experience.” referred to in these PTSD guidelines in section
2.3.6.1, which include “A hostile or mistrustful attitude towards the world; social withdrawal; feelings of emptiness and hopelessness; a chronic feeling of being “on
edge”, as if constantly threatened; and estrangement.” Often, in my experience, such patients present with depressed mood which is chronic and resistant to other
treatments. It should further be noted
that many patients with
personality disorders
diagnosed in adulthood have reported childhood maltreatment experiences (“Childhood maltreatment
increases risk for
personality
disorders
during early
adulthood”.
Johnson
et
al. Archives of General
Psychiatry. 1999. 56;
600-606). Practitioners
of
long-term psychodynamic psychotherapy
recognise readily
such
patients and with their
professional knowledge and clinical judgement (see above) will
recommend psychodynamic treatment
as
their experience is that
long-term
therapy can be helpful for
these patients.
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
This review of long-term psychodynamic psychotherapy in mental health conditions (document ‘C’) is open to
criticism, as noted above. The conclusion
drawn from a scrutiny of Cochrane reviews and NICE guidelines as to a lack
of a
good evidence base for LTPP overstates the case considerably
and may reflect the limited
nature of the
author’s
search process. There are surprising omissions in the appraisal of NICE
guidance particularly in respect
of
personality disorder. The limitations
of
NICE guidelines in cases of complex trauma and the implications
of these for decisions about therapy are not noted. Concerns about aspects of the methodologies used in
the
series of meta-analytic studies cited are unreasonably taken to undermine the
findings of the studies. More recently published research in the field of LTPP has not been found in the
author’s search.
The principal paper, document ‘A’, then cites evidence as to the effectiveness of cognitive behavioural therapy across a variety of diagnoses.
I will not contest this as
patients clearly
should have access to all available
effective treatments.
Similarly the evidence
cited
for dialectical
behaviour
therapy stands
scrutiny, although
the
equivalence at least, of psychodynamic therapy with DBT will be discussed later in Section Three of this paper.
The paper entitled “Systematic Review of Efficacy and Clinical Effectiveness of Group Analysis and Analytic/Dynamic Group Psychotherapy” next cited notes that group
therapies are effective but that it is not possible to
differentiate any greater (or lesser) effect for psychodynamically
orientated therapies
compared
to
other
treatment modalities.
Further research work is required. This is a familiar
message for psychodynamic psychotherapists. It is pertinent to note that in this study by the Sheffield University Centre for Psychological Services Research that more than half of the
studies in the analysed data
set
were
observational in nature. As
the PCT document is citing this SHARR 2004 research I take it that the PCT is accepting the validity of observational studies
as meaningful evidence.
Document
‘A’
summarises
by noting
some
of
the difficulties
inherent
in
the
development of a knowledge and evidence base in the effectiveness of
psychotherapy in patients with complex disorders. I would
comment that despite the many difficulties a sound knowledge base is developing and in Section Three of this
paper I will speak to recent research findings to support this
viewpoint.
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
It is encouraging to read that the commissioners want to see the best effective outcomes for their patients.
Long-term psychodynamic psychotherapy does indeed
offer this for their more seriously
troubled service users (Leichsenring and Rabung,
British Journal of
Psychiatry 2011. 199;
15-22).
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
Part Three
Recent Developments in
the
Evidence Base
In this part I offer an account of recently published empirical
research studies in the
field of long-term
psychodynamic
psychotherapy and its application
in the
more
serious end of the
spectrum of patients
suffering from mental health disorders.
A) In the Harvard Review of Psychiatry. 2009. 17; 1-23 S de Maat and others have
published a review entitled
“The Effectiveness of Long-Term Psychoanalytic
Therapy: A Systematic Review
of Empirical
Studies”. The authors are psychiatrists and clinical psychologists from academic institutions in Holland.
The
Harvard Review is a leading health journal published in the U.S.A.
Their
paper
contains
meta-analyses
of outcomes for
long-term psychodynamic psychotherapy based on high quality
observational studies with moderately to severely ill patients. Effect sizes are calculated
for a range of outcome
domains and sub-group analyses are performed.
The authors conclude that “Our data
suggests that LPT is effective treatment for a large range of pathologies, with moderate to
large effects”.
Observational, cohort studies fall short of the highest levels in any system of
ranking of evidence but still
provide important information concerning the effectiveness
of interventions. The methodology
often
allows a closer
reflection of real-life clinical practice. As noted in Section Two of
this paper the
PCT
has included a review based substantially on observational studies in its
posted evidence base.
B) Professor Leichsenring and
Dr
Rabung
are
academic clinicians
working in mental health
clinics in Germany. They
have a well established expertise in the
systematic
reviewing
of
psychological therapies and
in
the use
of meta-
analyses. They have published an update of their meta-analytic study of long- term
psychodynamic psychotherapy
in
the British Journal of Psychiatry
(Leichsenring and Rabung.
British Journal of
Psychiatry. 2011. 199; 15-22).
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The Case for Long-Term Psychodynamic
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A response to the Derbyshire County Primary Care Trust
This journal is one of the world’s leading psychiatric
journals and any articles
published are extensively
peer-reviewed. Their paper, entitled “Long-term
Psychodynamic Psychotherapy in complex mental disorders: update of a meta-
analysis”, takes into account criticisms made of an earlier
study (Leichsenring and Rabung. J.A.M.A. 2008. 300; 1551-64) and adds data from more recently
published randomised controlled trials. At the heart of the paper is a meta- analysis of controlled trials of LTPP. The authors found only low to moderate statistical heterogeneity in the data and defend against any criticism of clinical heterogeneity as useful because it permits greater generalisation and applicability
of the results. The number of studies included is small but their quality is high.
Some between group effect size assessments were carried out
and
outcome data are presented both pooled and broken down into clinically
relevant domains. The risk of publication bias was assessed. The authors
conclude that
long-term
psychodynamic
psychotherapy is superior
to less
intensive forms of psychotherapy in complex mental disorders. The effect size calculated indicates a moderate to
large effect.
Meta-analytic
studies of controlled trials
are
recognised as providing
the highest level of ranked
evidence. This study reinforces a conclusion of clinically significant efficacy of LTPP in a generic sense.
The treatment works and works
well.
C) Mentalisation – based therapy is a form of LTPP recommended by NICE in its
guidelines on borderline personality disorder. In the
American Journal
of
Psychiatry (American
Journal of Psychiatry.
2008.
165; 631-8)
Professors
Bateman and Fonagy have published a follow up study of the patients treated
in the trial
cited by NICE in a paper entitled “8 year Follow Up of Patients treated for Borderline Personality Disorder: Mentalisation – Based Treatment
Versus Treatment as Usual”. The authors, both leading academic clinicians in the
field,
show
that five
years after
discharge from
Mentalisation-based
treatment, the mentalisation-based treatment by partial hospitalisation group
continued to show clinical and statistical superiority to treatment as usual on a
variety of outcome measures in a range of outcome domains. For
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
psychological therapy research studies this is a very long follow-up period and
encouragingly indicates the continuing benefit that LTPP can offer for a highly
disturbed group of patients treated in a specialist day hospital setting.
D) The American Journal of Psychiatry is perhaps the world’s leading such journal.
In Winter 2010 the journal published an important new study by Bateman and
Fonagy entitled “Randomised Controlled Trial of Outpatient Mentalisation –
Based Treatment
versus
Structured
Clinical Management for Borderline
Personality Disorder” (American Journal of Psychiatry. Winter 2010. 8; 55-65).
This study compared MBT conducted on an outpatient basis, that is without partial hospitalisation or, as we would say in the UK, day hospital care, with
structured clinical management or, as we might say high quality treatment as
usual in a general psychiatric clinic. Patients in both groups improved across a range of
outcome domains but
improvement in
the MBT group was
significantly greater. Interestingly this difference became apparent only after
some twelve months of
therapy, indicating the necessity
of
a
longer
programme of
treatment with this
client group.
This study is of particular importance because it is the kind of research that
NICE
recommended
in
its guidelines
document
in
borderline personality
disorder in order for its recommendation for this form of long-term therapy to be further strengthened.
It is important also in that the study was conducted in an NHS
outpatient psychodynamic psychotherapy
service
with a clinical population
very much reflective of a ‘real-life’ situation.
What worked in this study for these seriously troubled patients should be able to be
applied
in other NHS outpatient psychodynamic psychotherapy services.
E) Dialectical behaviour therapy (DBT) is a long term treatment for borderline
personality disorder with
a
good
supporting
evidence base. The PCT
is proposing in its draft service specification for Tier
4 Psychological
Therapy Services to provide for small number of patients to be offered this therapy. In
June
2007 the American
Journal of Psychiatry
published a research
study
comparing
the effects of this
treatment
with two forms
of
long-term
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The Case for Long-Term Psychodynamic
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A response to the Derbyshire County Primary Care Trust
psychodynamic psychotherapy, transference-focused psychotherapy (TFP) and supportive psychodynamic
treatment. (J.F. Clarkin et al. American Journal of
Psychiatry. June 2007. 164; 922-928). The authors, three clinical psychologists
and one psychiatrist are recognised experts in the
field of
psychological
therapy for people with personality disorder. The studied patients were seen as outpatients, generally
in therapists’ offices. The authors conclude that there
was a
broad equivalence in the (good) outcomes achieved
for patients in all
three treatment
modalities with transference-focused psychotherapy (TFP)
achieving positive change in a greater number of outcome domains compared with the other
two forms of therapy.
A further randomised controlled study of transference-focused psychotherapy
(TFP) was reported on in the British Journal of Psychiatry in 2010 (S. Doering et
al. “Transference-focused Psychotherapy v. treatment by community
psychotherapists for Borderline
Personality Disorder: randomised controlled trial”. Brit. Journ. Psychiat. 2010. 196: 389-395). This research showed that the effects of TFP exceeded those of experienced
community therapists’
treatment in a range of outcome domains and that overall outcomes were good in both
groups.
Again, these are important pieces of research illustrating what can be achieved with
individual
long-term
psychodynamic
psychotherapies
in
an
outpatient
setting. Choice of psychological therapy is seen as important by clinicians and is promoted by NICE in its guidelines as it is recognised
that patients might
prefer and respond to different therapeutic approaches.
The research publications cited illustrate
that the field of research into long-
term psychodynamic
psychotherapy is a growing
one
and while it is
still
developing there can be seen to be an increasing robustness in a conclusion of efficacy and effectiveness of the therapeutic approach particularly in people with personality disorder. When applied in practice with appropriate
patients the effects of LTPP are moderate to good and most patients gain some benefit.
In one study undertaken with patients suffering at intake into the research
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The Case for Long-Term Psychodynamic
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A response to the Derbyshire County Primary Care Trust
from a C-type personality disorder, 54% no longer had the diagnosis at follow- up when they had been treated with psychodynamic psychotherapy compared to
46% who recovered with a cognitive-behavioural therapy (Svartberg et al. American Journal of Psychiatry. 2004. 161; 810-7) This is a very encouraging
outcome finding indicating what can be achieved with high quality services for
patients with personality
disorder.
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The Case for Long-Term Psychodynamic
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A response to the Derbyshire County Primary Care Trust
Part Four
Implications
for Local Services in Derbyshire
In many respects it seems to me entirely regrettable that this debate on the place of
long-term therapy is being
conducted in the context of a consultation about the
commissioner’s current proposal to close the long-term psychodynamic
psychotherapy service based
in
Derby. The process
is rushed and
has become
somewhat adversarial in nature when it should be neither.
It is, after all, only some five or six years since the Primary Care Trust commissioned a wide ranging review of
psychological therapy services in the county (Report included). Known locally as “The Shapiro Report” after its principal author this involved all stakeholders across the
health community
including services-users, their carers and families, and primary care workers, counsellors and general practitioners, together with voluntary agencies and
secondary
care providers
from the
mental
health trust, mainly, but not exclusively, clinical psychologists and specialist psychotherapists.
Shapiro Report
In this review, which was accepted
in
2006 by
the joint planning forum
set
up between the PCT and the Mental
Heath Trust, no question
was raised about the place of long-term psychodynamic psychotherapy and its importance in the care of the more seriously ill patient.
Moreover, in section 5.1 of the report, which is in fact entitled “Service Specification for Psychological Therapies”, it states that “Providers should ensure
that - those at greatest
risk, and
those
most
disabled by
their difficulties
should be our highest priority, but that resources should be spread across the care pathway”. It is the common experience of mental health practitioners and it would be intuitively understood by non professionals and service-users and their
families, that people
who are the “most disabled by their difficulties”
will need a longer period in care and treatment than those with lesser, albeit still troubling, problems. The PCT’s
new proposals
for a service specification for
psychological
therapies allow for only 30 sessions of treatment in most instances. This will fall well
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
short of the treatment lengths necessary to help the more severely ill patients.
The provision for 40 patients to receive 100 sessions of dialectical – behaviour therapy is,
of course, welcome but still falls very far short of what is required for the numbers of patients suffering from borderline personality disorder and, of course, it offers the
patient and
their family no choice
of treatment
modality. Furthermore DBT is
designed for one type of personality disorder only when most personality disorder
sufferers have mixed or not-otherwise-specified disorders or personality disorders of a different kind, such as a type-C disorder. It should be recalled, also, that the only comparative,
head-to-head trial of DBT and LTPP indicated an equivalent effect for
the
treatments. NICE
recommends
DBT but it also makes clear that a choice of psychological
treatment is necessary
and mentalisation
based therapy (MBT)
is
recommended as an evidenced alternative. As illustrated in Section Three of this
paper further research has reinforced the findings of effectiveness for MBT and has
explored a widened scope of application to include therapy in out-patient settings. MBT appears to be a therapy where competency in the treatment method is readily
acquired particularly by
those
therapists with
a
generic
psychodynamic
training.
Local services for borderline personality disorder patients in Derbyshire should offer MBT and with sufficient capacity to meet the needs identified from epidemiological
studies. The PCT should, as NICE advises, be commissioning a specialist personality disorders
service.
NICE guidelines
do not
cover by any means
all the patients who historically
have been treated with
LTPP in
services
in
Derbyshire. There are those for instance with complex trauma often with an associated personality disorder whose care needs, as noted, NICE has not pronounced upon. NICE does, however,
make it clear that healthcare
workers have a responsibility
to use their professional knowledge and
clinical experience in advising and treating patients not covered in their guidelines.
These same expectations should surely apply to service planners, such as commissioning PCTs. A PCT should assess the evidence for treatments, including in this the opinions of expert clinicians, for disorders not covered by NICE guidance. It
cannot be acceptable for clinical services to have to say to a patient with a complex
disorder that “your
difficulties are not in
NICE guidelines
so we cannot treat you”.
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The Case for Long-Term Psychodynamic
Psychotherapy:
A response to the Derbyshire County Primary Care Trust
To reduce the argument to a point of absurdity it is the case, to the best of my
knowledge,
that NICE has
not yet published
guidelines on
the management of
patients with acute appendicitis but I doubt if the PCT is proposing not to fund
surgical services to perform appendicectomies
in
such seriously
ill
people.
The experience of specialist psychodynamic
psychotherapists in Derbyshire
is
that
patients with
complex
trauma
and
personality disorder
can
be helped with
psychodynamic psychotherapy and that for the more ill of such people therapy has
had
to be of a long-term nature
Long-term
psychodynamic
psychotherapy
is
of proven efficacy in complex and
serious mental health disorders such as personality disorder and complex trauma.
It has a robust evidence base. As an evidence-based treatment long-term
psychodynamic psychotherapy should
continue to be made available for the people of Derbyshire by the Primary
Care Trusts who
commission services on their
behalf.
Dr David
Smith
M.B., B.S., M.R.C. Psych.
October 2011
