IN EVIDENCE
Measurement-based care can guide clinical practice in psychoanalysis
BY STEVEN ACKERMAN AND KATIE LEWIS
Illustration by Austin Hughes
How do we know when psychoanalysis works? While outcome assessment is common practice in the fields of medicine and mental health, some psychoanalysts have disputed its relevance, role, and purpose, deeming it overly simplistic, beside the point, or even dehumanizing to patients. In contrast, those involved in psychoanalytic research have long pointed out the necessity of evidence-based practices if psychoanalytic treatments are to be widely understood, appreciated, and applied. And in fact, since the late 1960s, over 300 randomized control trials have been published that demonstrate psychoanalytic treatments’ superiority over inactive control groups and noninferiority to other forms of evidence-based treatment (see Review of Research below).
In addition to proving psychoanalytic treatments effective, research can help guide and improve the care provided. One evidence-based practice model, measurement-based care (MBC), gives patients an important opportunity to provide information about the ways they suffer while also offering feedback about their experiences in psychoanalytic treatment. The use of MBC allows the patient to become a primary stakeholder in the process of identifying meaningful change in mental health treatment. In this article, we provide one example of an approach to developing an MBC project that we believe can meaningfully inform the care and treatment of patients in a psychoanalytic residential treatment setting.
MBC is a model of assessment intended to both define patient attributes and evaluate the quality of their outcomes. In contrast to psychological testing, which may be requested to clarify questions or concerns related to individual patients, MBC projects are developed with the goal of capturing aspects of functioning that are relevant across a given patient population (e.g., within a specific treatment setting), identifying differences in functioning for individual patients over the course of treatment as well as in comparison to peers. When used to inform individual treatment, MBC can expose hidden treatment barriers such as ruptures in the relationship between patient and therapist and negative reactions to the care provided. It can also engage patients in understanding gains and losses in specific domains (e.g., work and relationships). Furthermore, MBC can usefully assess what factors contribute to meaningful change over the course of treatment.
Recently, we implemented an MBC project at the Austen Riggs Center (ARC). ARC is a small, private, open psychiatric treatment setting that provides psychoanalytically informed residential care for treatment-resistant patients. One of the pillars of the treatment at ARC is acknowledging and promoting patient authority by encouraging patients to have an active voice in their work. Echoing broader areas of disagreement within the psychoanalytic field, one of the tensions at ARC is between (1) our desire to remain in dialogue with the larger world of mental health regarding empirical and clinical assessment and (2) maintaining a psychoanalytic, person-centered approach which anticipates ambiguity, nuance, and complexity in functioning over time.
The MBC project at ARC asks patients to routinely complete a series of measures to evaluate their progress and growth in several areas. The belief is that this type of systematic assessment can help us further understand how individuals suffer and the effectiveness of psychoanalytic treatment conducted in a residential setting. Because analytic work can provide a rich source of data for research to capture, MBC could contribute very importantly to a psychoanalytic approach to understanding people and to mental health treatment in general.
While one objective of MBC frameworks is to facilitate a dialogue with the broader field of mental health through a shared emphasis on specific areas of functioning, we recognized that the ultimate value and legitimacy of this program would depend upon the actual relevance of the assessment to our clinical values and priorities. Therefore, our initial step in developing our MBC protocol was to engage in a discussion with clinical staff about what they would like to know about their patients (in a broad sense, not limited to specific cases), and what information they felt would meaningfully inform their clinical work. From their answers, we developed a list of domains to focus our measurement efforts. The domains included (1) individual personality style, such as a person’s ability to express emotions, the impact of adverse childhood events, and the ability to empathize; (2) clinical concerns such as suicide risk and substance use; (3) interpersonal relationships, including working alliance with therapist; and (4) general functioning including the ability to think clearly, performance at work, and overall well-being.
Next, we engaged current patients at ARC to explore what they would want to learn about themselves and what information they felt would be important for their treatment teams to know. We had some concerns that patients might view the MBC initiative as another bureaucratic demand being made on their time, potentially taxing already limited emotional resources. Instead, our patients were deeply invested in understanding the nature of their suffering and viewed the MBC initiative as a meaningful part of the treatment process. Encouragingly, patients felt that the list of domains generated by clinical staff was consistent with their interests. One suggestion provided by our patients was that we should assess their strengths as well as their challenges; we ultimately incorporated measures assessing hopefulness, optimism, self-confidence, and ability to have fun to address this important point.
A multidisciplinary team reviewed the list of domains and worked to identify valid measurement tools that could reliably capture meaningful data. We used an iterative process of reviewing published literature, holding focused meetings to discuss individual measures, and selecting the measure we felt captured the clinical domain of interest. Our priorities in selecting measures were to attend to relevance to clinical needs, psychometric properties, length of administration, and accessibility. This process led to the selection of eight measures which are completed at different points in the treatment.
While the MBC program is launched and data collection is underway, we view our primary challenge going forward as the need to develop a method for providing meaningful feedback to individual patients and their treatment team. Feedback about individual results may not only increase the meaning and value of assessments to patients and their teams, but also create an opportunity for maintaining an ongoing open dialogue with patients on their interests and values in the outcomes assessment process, as well as support patient agency and authority in their treatment.
In our experience of implementing an MBC initiative at ARC, we have found that concerns over whether this approach to measurement may be inherently disruptive to the process of treating patients are unfounded, and in fact the collaborative development of such a program has facilitated greater interest and investment in treatment. Evidence from the last several decades in fact has shown that information collection methods like MBC enhance the effectiveness of psychoanalytic treatment by identifying potential ruptures and negative outcomes before they fully develop. Early identification of these types of treatment disruptions means they can be addressed, understood, interpreted, and used to deepen the work. More importantly, the implementation of MBC can help us to understand what is most important to our patients and help them achieve meaningful goals. ■
Steven Ackerman, PhD, MBA, ABPP, is a treatment team leader, psychotherapist, consultant to the therapeutic community program, accreditation manager, and chair of the Institutional Review Board at the Austen Riggs Center. He researches the therapeutic alliance through the interaction between personality, psychopathology, and psychotherapy process.
Katie Lewis, PhD, is the director of research at the Austen Riggs Center. Her research examines short-term changes in suicidal thoughts and interpersonal functioning using experience sampling methods. She has published on a range of topics, including suicidality, social connection, and multimethod personality assessment.
Review of research
There is extensive scientific evidence, collected over several decades, that psychodynamic and psychoanalytic treatment is an effective and clinically useful approach for treating many complex psychiatric problems such as severe character disorders, traumas, borderline personality disorder, anxiety, and depression (1). On this basis, experts agree that psychodynamic and psychoanalytic treatment is empirically based and a standard part of contemporary psychiatric practice (2). In fact, standard practice guidelines issued by major organizations such as the American Psychiatric Association include psychodynamic psychotherapy among other evidence-based treatment options (3).
Since the late 1960s, over 300 randomized control trials have been published which show conclusively that psychodynamic treatment is superior to inactive comparison groups and is not inferior to other active evidence-based treatments (4–11). These findings support the notion that psychodynamic treatment is as effective as other forms of active treatment. They also demonstrate the efficacy of psychodynamic and psychoanalytic treatments in reducing symptom severity and improving quality of life across a broad and diverse range of patient populations and treatment settings.
The work conducted by these research groups has helped address basic questions about whether psychoanalytic treatment “works” when compared to other treatment approaches for certain disorders. Improvements in these trials have been defined in various ways, from general symptom domains (e.g., depression, anxiety), to interpersonal functioning (e.g., severity of interpersonal problems, relationships quality), perceived quality of life, and specific clinically relevant behaviors (e.g., self-harm, substance use). A more limited number of studies have targeted outcomes that are more central to psychoanalytic models of the mind, most notably reflective functioning and mentalization capacities (12), level of personality organization (13, 14), and maturity of defense mechanisms.
References
1. Leichsenring, Falk, Frank Leweke, Susanne Klein, and Christiane Steinert. “The empirical status of psychodynamic psychotherapy-an update: Bambi’s alive and kicking.” Psychotherapy and Psychosomatics 84, no. 3 (2015): 129–148.
2. Oldham, John M. “Guideline watch: Practice guideline for the treatment of patients with borderline personality disorder.” Focus 3, no. 3 (2005): 396–400.
3. APA Practice Guidelines. http://www.psychiatryonline.com/pracGuide/pracGuideTopic_7.aspx.
4. Barber, Jacques P., Marna S. Barrett, Robert Gallop, Moira A. Rynn, and Karl Rickels. “Short-term dynamic psychotherapy versus pharmacotherapy for major depressive disorder: A randomized, placebo-controlled trial.” The Journal of Clinical Psychiatry 73, no. 1 (2012): 66–73.
5. Barkham, Michael, David A. Shapiro, Gillian E. Hardy, and Anne Rees. “Psychotherapy in two-plus-one sessions: Outcomes of a randomized controlled trial of cognitive-behavioral and psychodynamic-interpersonal therapy for subsyndromal depression.” Journal of Consulting and Clinical Psychology 67, no. 2 (1999): 201–11.
6. Cooper, Peter J., Lynne Murray, Anji Wilson, and Helena Romaniuk. “Controlled trial of the short-and long-term effect of psychological treatment of post-partum depression.” The British Journal of Psychiatry 182, no. 5 (2003): 412–419.
7. de Jonghe, Frans, Mariëlle Hendricksen, Gerda van Aalst, Simone Kool, Vjaap Peen, Rien Van, Ellen van den Eijnden, and Jack Dekker. “Psychotherapy alone and combined with pharmacotherapy in the treatment of depression.” The British Journal of Psychiatry 185, no. 1 (2004): 37–45.
8. Driessen, Ellen, Lisa M. Hegelmaier, Allan A. Abbass, Jacques P. Barber, Jack J. M. Dekker, Henricus L. Van, Elise P. Jansma, and Pim Cuijpers. “The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update.” Clinical Psychology Review 42 (2015): 1–15.
9. Leichsenring, Falk, Simone Salzer, Manfred E. Beutel, Stephan Herpertz, Wolfgang Hiller, Juergen Hoyer, Johannes Huesing, et al. “Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder.” American Journal of Psychiatry 171, no. 10 (2014): 1074–1082.
10. Levy, Kenneth N., Kevin B. Meehan, Kristen M. Kelly, Joseph S. Reynoso, Michal Weber, John F. Clarkin, and Otto F. Kernberg. “Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder.” Journal of Consulting and Clinical Psychology 74, no. 6 (2006): 1027.
11. Svartberg, Martin, Tore C. Stiles, and Michael H. Seltzer. “Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders.” American Journal of Psychiatry 161, no. 5 (2004): 810–817.
12. Suchman N. E., Cindy L. DeCoste, Thomas J. McMahon, Rachel Dalton, Linda C. Mayes, and Jessica Borelli. “Mothering from the Inside Out: Results of a second randomized clinical trial testing a mentalization-based intervention for mothers in addiction treatment.” Development and Psychopathology 29, no. 2 (May 2017): 617–636. DOI: 10.1017/S0954579417000220.
13. Leichsenring F. “Development and first results of the Borderline Personality Inventory: A self-report instrument for assessing borderline personality organization.” Journal of Personality Assessment 73, no. 1 (Aug 1999): 45–63. DOI: 10.1207/S15327752JPA730104.
14. Ulberg, Randi, Benjamin Hummelen, Anne Grete Hersoug, Nick Midgley, Per Andreas Høglend, and Hanne-Sofie Johnsen Dahl. “The first experimental study of transference work–in teenagers (FEST–IT): A multicentre, observer- and patient-blind, randomised controlled component study.” BMC Psychiatry 21 (2021). DOI: 10.1186/s12888-021-03055-y.
Published in issue 57.3, Fall/Winter 2023