AMA PRA Category 1 Credits™cme.lww.com/files/TheCurrentStateoftheEmpirical...INTRODUCTION As a therapeutic discipline, psychoanalysis encompasses both short- and long-term treatment

Title: The Current State of the Empirical Evidence for Psychoanalysis: A Meta-analytic Approach

Activity Date: This activity will be available as an online learning module starting May 9, 2013, and will be available for one year.

Activity Location: Online

Target Audience Statement: This CME activity is intended for psychiatrists.

Accreditation: Lippincott Continuing Medical Education Institute, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation: Lippincott Continuing Medical Education Institute, Inc. designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Learning Objectives: After completing this activity, the learner should be better able to:

Evaluate the empirical evidence for pre/post changes in psychoanalysis patients with complex mental disorders

Assess the limitations of the meta-analysis

Faculty Credentials and Disclosure Information

Shelly F. Greenfield, MD, MPH Editor in Chief Harvard Review of Psychiatry Harvard Medical School Boston, MA Joshua L. Roffman, MD, MMSc Deputy Editor Harvard Review of Psychiatry Harvard Medical School Boston, MA Stephen Scher, PhD, JD Senior Editor Harvard Review of Psychiatry Harvard Medical School Boston, MA Dawn E. Sugarman, PhD Communications Editor Harvard Review of Psychiatry Harvard Medical School Boston, MA

Falk Leichsenring, PhD Professor University of Giessen Department of Psychotherapy and Psychosomatics Giessen, Germany Allan Abbass, MD Professor and Director of Education Dalhousie University Department of Psychiatry Halifax, Nova Scotia, Canada Patrick Luyten, PhD Professor of Clinical Psychology Faculty of Psychology and Educational Sciences University of Leuven Leuven, Belgium Senior Lecturer Research Department of Clinical, Educational and Health Psychology University College London, United Kingdom

Saskia de Maat, PhD Researcher Vrije Universiteit Amsterdam, The Netherlands Frans de Jonghe, PhD Psychiatrist Dutch Psychoanalytic Institute Arkin Mental Health Institution Amsterdam, The Netherlands Ruth de Kraker, MSc Psychologist Arkin Mental Health Institute Amsterdam, The Netherlands

Jacques P. Barber, PhD Dean and Professor The Derner Institute of Advanced Psychological Studies Garden City, NY Rien Van, MD, PhD Residency Program Director Arkin Mental Health Institute Amsterdam, The Netherlands Jack Dekker, PhD Head of Research Department Arkin Mental Health Institute Amsterdam, The Netherlands

All faculty members in a position to control the content of this CME activity have disclosed that they and their spouse/life partners (if any) have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.

LCMEI Staff and Planning Committee Members

All LCMEI staff members and planners in a position to control the content of this CME activity have disclosed that they and their spouse/life partners (if any) have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.

Method of Physician Participation in the Learning Process/Evaluation Method

Successful completion of this activity includes reading the entire article and successfully completing the postquiz and an evaluation form.

Getting the Most out of the Activity

As you prepare to participate in this activity, please reflect on your practice and your patients and identify clinical challenges you hope to have addressed.

While participating in the training, identify ways you can use newly acquired knowledge, strategies, and skills to enhance patient outcomes and your own professional development.

Disclaimer

Clinicians should ensure that all diagnostic and therapeutic modalities are prescribed and used appropriately, based on accepted standards of care. Use of any drugs, devices, and imaging techniques should be guided by approved labeling/full prescribing information, best available evidence, and professional judgment.

Faculty have been instructed that their content should be fair balanced and based on best available evidence. The information presented in this activity is the responsibility of the faculty and does not reflect the opinions of the provider

The Current State of the Empirical Evidence forPsychoanalysis: A Meta-analytic Approach

Saskia de Maat, PhD, Frans de Jonghe, PhD, Ruth de Kraker, MSc, Falk Leichsenring, PhD,Allan Abbass, MD, Patrick Luyten, PhD, Jacques P. Barber, PhD, Rien Van, MD, PhD,and Jack Dekker, PhD

Learning Objectives: After participating in this educational activity, the reader should be better able to evaluate theempirical evidence for pre/post changes in psychoanalysis patients with complex mental disorders, and assess thelimitations of the meta-analysis.Background: The effectiveness of psychoanalysis is still a controversial issue, despite increasing research efforts.Objective: To investigate the empirical evidence for psychoanalysis by means of a systematic review of the litera-ture and a meta-analysis of the research data.Method: A systematic literature search was undertaken to find studies regarding the effectiveness of psychoanalysis,published between 1970 and 2011. A meta-analysis was performed.Results: Fourteen studies (total n = 603) were included in the meta-analysis. All but one were pre/post cohort studies.At treatment termination, the mean pre/post effect size across all outcome measures was 1.27 (95% confidence inter-val [CI], 1.03–1.50; p < .01). The mean pre/post effect size for symptom improvement was 1.52 (95% CI, 1.20–1.84;p < .01), and for improvement in personality characteristics 1.08 (95% CI, 0.89–1.26; p < .01). At follow-up themean pre/follow-up effect size was 1.46 across all outcome measures (95% CI, 1.08–1.83; p < .01), 1.65 for symp-tom change (95% CI, 1.24–2.06; p < .01), and 1.31 for personality change (95% CI, 1.00–1.62; p < .01).Conclusions: A limited number of mainly pre/post studies, presenting mostly completers analyses, provide empiricalevidence for pre/post changes in psychoanalysis patients with complex mental disorders, but the lack of compari-sons with control treatments is a serious limitation in interpreting the results. Further controlled studies are urgentlyneeded.

INTRODUCTIONAs a therapeutic discipline, psychoanalysis encompassesboth short- and long-term treatment modalities, as pre-sented schematically in Figure 1.

The two long-term variants are long-term psychoana-lytic psychotherapy (LTPP) and psychoanalysis. The crite-rion most frequently used to differentiate between thetwo long-term modalities is the therapeutic setting, withthe main features being the frequency of the sessions and

the physical positions of the patient and the therapist. It isunderstood that in LTPP both patient and therapist are sit-ting on chairs facing each other, whereas in psychoanalysisthe patient is lying on a couch, and the therapist is sittingon a chair behind him or her. LTPP sessions usually occuronce or twice a week; in psychoanalysis the frequencyranges from two to five sessions a week. In this article weconcentrate on psychoanalysis proper.

Research has fairly well established the efficacy of LTPP;for example, Shedler,1 Leichsenring,2 and colleagues haveconducted meta-analyses, pooling evidence from multiplestudies and calculating pooled effect sizes (ESs). Thoughconsiderably less evidence is available concerning the effi-cacy of psychoanalysis, the effectiveness of psychoanalysishas been researched repeatedly. Several reviews and over-views have shown large ESs and conclude that between60% and 90% of the patients for whom psychoanalysis isindicated derive clinically significant change.3–8 Neverthe-less, no meta-analysis has been performed that systemati-cally pooled data specifically on psychoanalysis. Giventhat psychoanalysis is a long-term, intensive, and expensivetreatment, such an analysis of the available empirical datais urgently needed. In this article we present the firstmeta-analysis of studies examining the effectiveness ofpsychoanalysis.

From the Vrije Universiteit Amsterdam (Dr. deMaat); Nederlands Psychoanaly-tisch Instituut, Arkin, Amsterdam, theNetherlands (Drs. deMaat and de Jonghe);Arkin, Amsterdam, the Netherlands (Ms. Kraker; Drs. Van and Dekker); Univer-sity of Giessen (Dr. Leichsenring); Dalhousie University (Dr. Abbass); Universityof Leuven and University College London (Dr. Luyten); Derner Institute of Ad-vanced Psychological Studies, Adelphi University (Dr. Barber).

Original manuscript received 27 December 2011; revised manuscript re-ceived 16 July 2012, accepted for publication subject to revision 13 August2012; revised manuscript received 28 August 2012.

Correspondence: Jack Dekker, PhD, Klaprozenweg 111, 1033 NN,Amsterdam, The Netherlands. Email: [email protected]

Harvard Review of Psychiatry offers CME for readers who completequestions about featured articles. Questions can be accessed from

the Harvard Review of Psychiatry website (www.harvardreviewofpsychiatry.org) by clicking the CME tab. Please read the featured article and then log intothe website for this educational offering. If you are already online, click hereto go directly to the CME page for further information.

©2013 President and Fellows of Harvard College

DOI: 10.1097/HRP.0b013e318294f5fd

REVIEW

Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 107

http://journals.lww.com/hrpjournal/Pages/collectiondetails.aspx?TopicalCollectionId=1

Characteristics of PsychoanalysisAlthough psychoanalysis is considered a therapy requiringvery frequent sessions, there is no universal agreement onthe number of sessions. The International PsychoanalyticAssociation endorses three psychoanalytic training mod-els.9 According to the Eitington model, a frequency of fourto five sessions per week is required; in the French model,the session frequency is decided by the analyst and the pa-tient; and in the Uruguayan model, a minimum of three ses-sions a week is required. In Germany, a frequency of two tothree sessions a week is commonly employed, with the pa-tient lying on the couch. This format is called AnalytischePsychotherapie, and face-to-face, long-term psychoanalyticpsychotherapy is known as Tiefenpsychologisch fundiertePsychotherapie.10 To respect this international variancewe opted for a broad definition, including studies in which(1) the patient is lying on a couch, with (2) two to five ses-sions a week. We performed separate sub-analyses of stud-ies based on treatment frequency (divided into two groups):two to three sessions per week (on average, less than threeper week), and three or more sessions per week (on aver-age, three or more per week).

All psychoanalytic therapies, including psychoanalysis,are rooted in the psychoanalytic theories. Gabbard11 out-lines the basic principles as follows: much of mental life isunconscious; childhood experiences, in concert with ge-netic factors, shape the adult; the patient’s transference tothe therapist is a primary source of understanding thepatient’s character and pathology; the therapist’s counter-transference provides valuable information about whatthe patient induces in others; the patient’s resistance tothe therapy process is a major focus of the therapy; symptomsand behaviors serve multiple functions and are determined bycomplex and often unconscious forces; and the therapistassists the patient in achieving a sense of authenticity.

Despite these “common grounds,” there is presently nosingle, all-encompassing psychoanalytic theory—but onlymany partial theories. These theories can be roughly classi-fied into “classical” and “post-classical” views. The classi-cal views (Sigmund Freud and the “Freudians,” MelanieKlein and the “Kleinians,” and the “British Independents”)see intrapersonal conflict as central. Whether referred to asego psychology, a structural model, a drive-defense model,

or a one-person psychology, these approaches concentrateon the triadic relationships of the “oedipal situation,” char-acterized by sexual and aggressive needs. The post-classicalviews (with such forerunners as Ferenczi, Balint, and Sulli-van, the leaders of relational, interpersonal, intersubjectivepsychoanalysis, respectively) are developmental theoriesthat focus on “developmental needs,” including the needsto feel connected, seen, understood, loved, appreciated,and protected. Also referred to as a two-person psychology,these approaches concentrate on the dyadic relationships ofinfancy. In present-day psychoanalysis, the classical and post-classical views coexist. They are not only compatible, but alsocomplementary, to each other.

Personality pathology is a crucial concept in psychoana-lytic thinking.12 Psychoanalytic diagnostics basically differ-entiate between two main forms of personality problems:developmental pathology and conflict pathology (see, forexample, Fonagy & Moran).13 Broadly speaking, these twotypes of problems differ in two ways. The first differenceconcerns the dating of the origins of the pathology: devel-opment pathology relates to problems stemming from earlychildhood (before the fifth year), whereas conflict pathol-ogy relates to problems originating in childhood (aroundthe fifth year and later). The second difference concernsthe sort of innate human needs that the pathology mainlypertains to: development pathology focuses on develop-mental needs such as attachment needs, the need to be val-ued, seen, and loved, whereas conflict pathology considersthe needs of sexuality and aggression. The two kinds ofpersonality pathology do not exclude one another. Mostpatients present with both developmental pathology andconflict pathology.

Fundamental personality change is considered the goalof psychoanalysis, although its conceptualization dependson the theoretical approach used. It can be summed up aspersonality growth leading to more differentiation (e.g.,of self vs. other, or fantasy vs. reality) and greater integra-tion (of aspects of the self). In psychoanalytic terms, thechanges in personality are described as “structural change,”“personality change,” “personality reconstruction or con-struction,” or the development of a “cohesive,” “adult,” “in-tegrated” self, resulting, among other things, in a greatersense of inner freedom. The purpose of this fundamental

Figure 1. Psychoanalytic treatment: Modalities.

S. de Maat et al.

108 www.harvardreviewofpsychiatry.org Volume 21 • Number 3 • May/June 2013

change is ultimately for the patient to achieve symptomreduction, prevention of recurrence, better social function-ing, and higher quality of life (all persisting after treat-ment termination).

Psychoanalysis is indicated for patients with “complexmental disorders”14—usually a combination of long-standing,often unsuccessfully treated DSM-defined Axis I disorders(most often, mood disorders) and Axis II personality disor-ders.15 Several studies show that patients for whom psy-choanalysis is indicated suffer from these complex mentaldisorders.14,16–19

For psychoanalytically trained clinicians, a DSM diag-nostic classification is insufficient for a complete diagnosisand treatment choice. These clinicians aim to describethe personality structure of patients in terms of essentialpsychoanalytical concepts such as defense mechanisms,conflicts, internal object relations, and intrapsychic func-tioning. In addition, an attempt is made to offer hypothesesexplaining the development, maintenance, and recurrenceof pathology. In broad psychoanalytic terms, psychoanaly-sis is useful for moderate to severe conflict pathology andmild developmental pathology.

ResearchResearch in psychoanalysis is complex to conduct (seede Jonghe et al.).20 The treatments are of considerablelength, making it difficult to randomize patients to controlconditions that are substantially different from psychoanal-ysis (see also the discussion section). Study periods that in-clude follow-up are long; the research requires significantfunding; and the number of patients is limited. In addition,it is difficult to capture—whether in questionnaires, self-reports, or interviews—the process and outcomes that areconsidered relevant by psychoanalysts. Some analysts wouldeven argue that doing so is impossible and consider theresearcher an “unwanted third” in the treatment. Especiallydue to the problems of randomization, almost no random-ized, controlled trials (RCTs) have been conducted in thefield of psychoanalysis. Most studies on psychoanalysis fol-low a cohort of patients for whom psychoanalysis is indi-cated, and present pre/post changes. Early research in thisfield often defined outcome in terms of the therapist’s clinicaljudgment, reflecting a judgment concerning improvements inpersonality structure and growth. More recently, measure-ment instruments have become more common, as are RCTs.

METHODS

Search StrategyAn extensive literature search was conducted using differ-ent search methods. First, we searched the electronic data-bases PubMed, PsycInfo, Embase, Cochrane Database ofSystematic Reviews, and the Cochrane Central Register ofControlled Trials. The time frame was between January1970 and December 2009. The following search terms

were used: psychoanalysis (OR psychoanalytic OR ana-lytic), psychodynamic (OR dynamic OR interpretive ORinsight-oriented), therapy (OR psychotherap* OR counsel-ing), long-term (OR open-ended OR LTPP) and treatmentoutcome (OR outcome OR effective* OR efficacy). Thecomplete search terms are available on request. No limitswere set on language. Second, an Internet database of con-trolled and comparative outcome studies on psychologicaltreatments of depression was searched.21 Third, a manualsearch was performed on the Open Door Review6 andother reviews and meta-analyses.1–5,7,14 Cross-referencesin the retrieved publications were tracked down. For thetime period of 2010–11, we did not perform the literaturesearch again; instead, we contacted authors of studies thatwere known to us but whose findings had not yet been pub-lished. This third process resulted in two extra studies.

Selection of StudiesThe following inclusion criteria were applied:

• The studies were “outcome-intervention studies.” Theoutcomes had to be measured in terms of symptom re-duction or personality change. Issues such as processvariables were excluded from this review. Outcome mea-sures had to be reliable and valid, as supported by atleast one study on its reliability.

• Studies had to report on completed treatments; studiesin which large proportions (more than 25%) of treat-ments were still ongoing were excluded.

• Studies had to provide ESs; means and standard devia-tions on measurements; or percentages of patients achiev-ing clinically significant change.

• The studies were required to be RCTs; prospective, pre/post cohort studies (with or without comparison groups);or cross-sectional studies that included a minimum of tensubjects. Case studies or case series were excluded, aswere retrospective studies such as surveys.

• The studies were required to include adult patients (18 to65 years of age).

• The studies had to include only patients with the most“common” (i.e., the most frequently seen in clinical prac-tice) indications for psychoanalysis (i.e., DSM diagnoses[Axis I or II] or psychoanalytically specified symptomsor personality problems). Studies focusing on purely so-matic or psychotic disorders were excluded.

• The treatment was psychoanalysis, characterized as fol-lows: (1) patients were lying on the couch, with (2) twoto five therapy sessions a week. Whenever it was un-certain whether the treatment was psychoanalysis (so de-fined), we contacted the authors of studies to determinethe type of treatment.

Identification of Relevant Publications andQuality AssessmentUsing the selection criteria, two independent judges (SdMand FdJ) reviewed the titles and abstracts generated from

Empirical Evidence for Psychoanalysis


the searches. Disagreement was discussed and resolved byconsensus. In case of continued disagreement, a third re-viewer was consulted (JD). Titles and abstracts identifiedas potentially relevant were retrieved for full-text review.Two independent raters then examined whether the full-text articles met the inclusion criteria. Disagreement wasdiscussed and resolved by consensus. Studies with unre-solved disagreement were reviewed by a third rater.

Two reviewers (SdM and FdJ) evaluated the quality ofthe studies independently using a Research Quality Scorerating system (see Appendix 1). This rating system (devel-oped by the reviewers SdM and FdJ) follows the researchcriteria postulated by the Cochrane Collaboration andother researchers.22,23 This system assesses aspects of thestudy design, patients included, interventions, outcome data,statistics, dropout, and follow-up, and reflects the currentstandards of evidence-based medicine. Maximum scores andcutoff scores are mentioned in Appendix 1. Studies withunresolved disagreement were reviewed by a third rater(JD). We did not calculate interrater reliability.

Meta-analysesWe performed different meta-analyses, assessing pre- topost-treatment change and pre-treatment to follow-up change,applying these analyses to measurements of overall func-tioning, symptoms, and personality and psychosocial func-tioning. The pre- to post-treatment ES was calculated bysubtracting the average post-treatment score from the av-erage pre-treatment score and by then dividing the resultby the pooled standard deviations of both groups. The pre-treatment to follow-up ES was calculated by subtractingthe average follow-up score from the average pre-treatmentscore and by then dividing the result by the pooled standarddeviations of both groups. ESs of�0.20 are considered small;�0.5, medium; and�0.80, large (see Cohen),24 but these qua-lifiers applied originally to between-group ESs. Furthermore,Cohen also stated explicitly that the qualifiers were based onhis experience and were not empirically defined. Finally, pre-to-post ESs are usually larger than between-group ESs. Forthese reasons, we avoid using the qualifiers.

An overall mean ES was calculated on the basis ofall outcome measures used in a study. ESs for symptommeasures and for personality and psychosocial functioningmeasures were calculated separately. For calculating theoverall ES, a mean ES was calculated for each study thatpresented more than one ES. The ESs or the means andstandard deviations (whichever was presented) of individ-ual studies were used, in turn, as the basis for calculatingan overall mean ES, with the individual study ESs weightedto reflect the study’s sample size. To calculate the pooledmean ESs, we used the statistical computer program Com-prehensive Meta-analysis.25 We computed the pooled meanESs using the random-effects model because considerableheterogeneity of the included studies was expected.26 In therandom-effects model, the included studies are seen as a

sample drawn from a population of studies, rather thanreplications of each other, so that not only the randomerrors within the studies, but also the true variations ofESs from one study to the next, are taken into account. Therandom-effects model therefore results in broader 95% con-fidence intervals (CIs) and more conservative results. Moststudies did not report within-group correlations (correla-tions across time points). Therefore we used Cohen’s dfor the repeated-measures comparisons, as recommended byDunlap and colleagues.27

Finally, we calculated between-group ESs, comparingposttest means of psychoanalysis groups with means ofnonclinical norm groups (when the latter were available).

Tests for heterogeneity were calculated by using theQ-statistic.28 A significant Q-value rejects the null hy-pothesis of homogeneity. We also calculated the degreeof heterogeneity in percentages, using the I2-statistic.29 Avalue of 0% indicates no observed heterogeneity; a valueof 25%, low heterogeneity; and values of 50% and 75%,moderate and high heterogeneity, respectively.30

Publication bias was tested according to Duval andTweedie’s trim-and-fill procedure31 using ComprehensiveMeta-analysis. This procedure uses funnel plots (a distribu-tion of the expected studies in a field, based on study sizesand their expected ESs) to estimate the number of “missingstudies” in a meta-analysis and the effect that these studiesmay have had on its outcome. The method yields an esti-mate of the ES after publication bias has been taken intoaccount, meaning that the ESs expected to belong to the“missing studies” are taken into account. Adjusted valuesof the pooled mean ESs and 95% CIs are then calculatedand compared to the original findings of the meta-analysis.In this procedure, we also used the random-effects model.

A secondary outcome measure for the meta-analysis wasclinically significant change measured at treatment termina-tion (pre/post treatment) and at follow-up (pre/follow-up).The definitions of clinically significant change are mentionedin Table 8.

Subgroup AnalysesSubgroup analyses were carried out using ComprehensiveMeta-analysis.25 Studies were divided into two or moresubgroups. Initially, a pooled mean ES was calculated foreach subgroup. It was then determined whether the pooledmean ESs differed significantly between subgroups. Themean pooled ESs were computed using the mixed-effectsmethod of subgroup analyses, which pools studies withinsubgroups according to the random-effects model, buttests for significant differences between subgroups accord-ing to the fixed-effects model.

The following subgroup analyses were conducted, basedon the following:

• Study quality: studies with higher quality scores versusstudies with lower quality scores

S. de Maat et al.


• Study design: prospective studies versus studies thathad a cross-sectional design (the latter included differentpatient groups at the beginning and at the end of treatment)

• Continent of study: Europe versus North America• Frequency of sessions: studies with two to three ses-

sions (with an average below three) per week and stud-ies with three or more sessions per week (with anaverage of three or more)

• Duration of follow-up: studies with follow-up of up toone year versus studies with follow-up of more thanone year

• Symptom-specific sub-analyses: for all studies, only in-struments for measuring depression

• Across all studies, patient ratings versus therapist ratingsversus observer ratings

RESULTS

Results of the Literature Search: Trial FlowA flow chart showing the process of study selection is givenin Figure 2. After screening titles and abstracts, 164 titleswere requested in full text and screened by two raters.

Figure 2. Flow chart of studies identified for review.



Table1

Includ

edStud

ieson

Psycho

analysisa

Study

Studytype

&Resea

rch

Quality

Score

Trea

tmen

ts&

no.ofsubjects

Diagn

osesin

psych

oan

alysis

group

Duratio

n(m

ean

years&

sessions)

Outcome

source

Mea

sure

of

effectiven

ess

Assessm

ent

points

Country

Kernberget

al.(1972)69

Harty&Horwitz

(1976)70

Wallerstein

(1986)68

(42Live

sin

Trea

tmen

t)

Cohort,

prospec

tive

RQS:

54

Psycho

analysis:2

2

Psycho

therap

y:20

Person

ality

organizatio

n(Kernbergcrite

ria):

Borderlin

epersonality

organ

ization:50%

Alcohol/d

rug

abuse:35%

Paran

oid

traits:33%

4.4

years;

730sessions

Patient:−

Therap

ist:+

Observer:−

Other:−

Symptoms:HSR

S

Personality

:CGI-I

Pre:+

During:

−Post:+

Follo

w-up:−

USA

Kan

trowitz

etal.(19

75,

1986

,198

7,19

90)53–59

Cohort,

prospec

tive

RQS:

43

Psycho

analysis:2

2Neu

rotic

:37%

Narcissistic

:14%

Borderlin

e:23%

Borderlin

ewith

psych

otic

proce

sses:14%

Psych

otic

charac

ter:14%

4.5

years;

810sessions

Patient:+

Therap

ist:+

Observer:+

Other:−

Personality

(%):

analyz

ability,

affect

availability,

reality

testing,

quality

ofob

ject

relatio

ns

Pre:+

During:

−Post:+

Follo

w-up:+

USA

Kordyet

al.(1988)66

Heu

ftet

al.(1996)65

vonRad

etal.(1998)64

(HeidelbergKatam

nese

Study)

Cohort,

prospec

tive

RQS:42

Psycho

analysis:3

6

Psycho

therap

y:33

Men

taldisorder:21%

Functional

disorder:18%

Psych

osomatic

disorder:10%

Psych

iatric

disorder:58%

Psych

oan

alysis:

3.7

years(?);

350sessions

Psych

oan

alytic

psych

otherap

y:2.2

years(?);

150sessions

Patient:+

Therap

ist:+

Observer:+

Other:−

Symptoms(%

):Clin

ical

Global

Impressionof

symptom

chan

ge,therap

ygo

als,satisfaction

with

therap

y

Pre:+

During:

+

Post:+

Follo

w-up:+

German

y

Rudolfet

al.(1994)67

(Berlin

Psych

otherap

yStudy)

Cohort,

prospec

tive

RQS:

30

Psycho

analysis:4

4

Psycho

therap

y:56

Inpa

tients:16

4

(ICD-8

diagn

oses)

Psych

oneu

rosis:54%

Psych

osomatic

complaints:13%

Somatopsych

icdisorder:8%

Egowea

kness:5%

PD:20%

Psych

oan

alysis:

2.65–3

years,

265sessions

Psych

oan

alytic

psych

otherap

y:1.5

years;

60sessions

Patient:+

Therap

ist:+

Observer:−

Other:−

Symptom

scales

ofPSKB&PSKB-Se

Personality

scales

ofPSK

B&

PSK

B-Se

Pre:+

During:

−Post:+

Follo

w-up:−

German

y

Contin

ued

onnextpage

S. de Maat et al.


Table1

Con

tinue

d

Study

Stud

ytype

&Research

Qua

lity

Score

Trea

tmen

ts&

no.ofsubjects

Diagn

osesin

psych

oan

alysis

group

Duration(m

ean

years&sessions)

Outcome

source

Mea

sure

of

effectiven

ess

Assessm

ent

points

Country

Sandellet

al.(2000)16

(Stock

holm

Outcome

ofPsych

oan

alysis&

Psych

otherap

yProject)

Cohort,

prospec

tive

(cross-sec-

tiona

lde-

sign

)

RQS:

35

Psycho

analysis:7

4

Psycho

therap

y:33

1

AxisIdisorder:55%

V-code:

36%

AxisIIdisorder:1

1%

(meanGAF,61

;previoustrea

tmen

t,91%;clinical

case,

88%)

Psych

oan

alysis:

4.25ye

ars,

650sessions

Psych

oan

alytic

psych

otherap

y:3.3

years;

240sessions

Patient:+

Therap

ist:−

Observer:−

Other:−

Symptoms:

SCL-90

Personality

:

SOC,SA

S(casenesscriterio

n:on

3scales,

inworst10

%)

Pre:+

During:

+

Post:+

Follo

w-up:

+

Swed

en

Luborskyet

al.(2001)63

(Pen

nPsych

oan

alytic

Trea

tmen

tColle

ction)

Cohort,

prospec

tive

RQS:

28

Psycho

analysis:1

7Patientsev

aluated

assuita

ble

for

psych

oan

alysis

(mea

nea

rlyGAF,58;

mea

nea

rlyHSR

S,59)

Unkn

own

Patient:−

Therap

ist:−

Observer:+

Other:−

Symptoms:GAF,

HSR

S(global)

Personality

:HSR

S(m

eanof

7crite

ria)

Pre:+

During:

+

Post:+

Follo

w-up:

+

USA

Erle

&Goldb

erg(200

3)48

(New

York

Stud

yII)

Cohort,

prospec

tive

(1984–8

9)

RQS:

28

Psycho

analysis:9

2

(9caseson

going)

Patientsev

aluated

assuita

ble

for

psycho

analytic

therap

y

(previou

stherapy,70

%)

5ye

ars;

840sessions

Patient:−

Therap

ist:+

Observer:−

Other:−

Clin

ical

Global

Impression(e.g.,

functioning,

symptoms,

defen

ses,object

relatio

ns,

self-esteem

)

Pre:+

During:

+

Post:+

Follo

w-up:

−

USA

Rudolfet

al.(2004)50

Grandeet

al.(2006)49

(Heidelberg-Berlin

PAL

Study)

Cohort,

prospec

tive

RQS:

48

Psycho

analysis:2

7

Psycho

therap

y:32

(ICD-10diagn

oses)

Dep

ression:66%

Anxiety:

44%

Somatoform

disorder:31%

Obsessiveneu

rosis:

31%

Sexu

aldisorder:25%

Eatin

gdisorder:28%

PD:53%

Psych

oan

alysis:

3.7

years;

310sessions

Psych

oan

alytic

psych

otherap

y:2ye

ars;

71sessions

Patient:+

Therap

ist:−

Observer:−

Other:−

Symptoms:

SCL-90

Personality

:IIP

Pre:+

During:

−Post:+

Follo

w-up:

+

German

y

Contin

ued

onnextpage



Table1

Con

tinue

d

Study

Stud

ytype

&Research

Qua

lity

Score

Trea

tmen

ts&

no.ofsubjects

Diagn

osesin

psych

oan

alysis

group

Duration(m

ean

years&sessions)

Outcome

source

Mea

sure

of

effectiven

ess

Assessm

ent

points

Country

Coga

n&

Porcerelli

(2005)47

Cohort,

prospec

tive

(cross-sec-

tionald

esign)

RQS:

27

Psycho

analysis:5

2AxisIdisorder:96%

AxisIIdisorder:65%

(Cluster

A,14%;

Cluster

B,29%;

Cluster

C,10%;

NOS,

19%)

(additional

med

ication,

68%)

Psycho

analysis:

5.9years;94

4sessions

Patient:−

Therap

ist:+

Observer:−

Personality

:SW

AP-200

Pre:−

During:

−Post:+

Follo

w-up:

−

USA

Leichsenring

etal.(2005)61

(Göttin

genStudy)

Cohort,

prospec

tive

RQS:

44

Psycho

analysis:3

6(IC

D-10diagn

oses)

Affectivedisorder:6

9%

Phob

icdisorder:5

0%

Anx

iety

(other):25

%

Obsessive-com

pulsive

neurosis:2

8%

Somatoform

disorder:

36%

PD:69%

(problemsin

relatio

nships,88%;

dysfunctional

inwork,

42%;co

morbidity,

88%–1

00%;3

ormore

disorders,82

%)

3.1

years;

253sessions

Patient:+

Therap

ist:−

Observer:−

Symptoms:

SCL-90,mGAS

Personality

:IIP

Pre:+

During:

+

Post:+

Follo

w-up:

+

German

y

Bergh

out/Zev

alkink

etal.(2006–1

0,

2012)32–46

(DutchNPIStudy)

Cohort,

prospec

tive

(cross-sec-

tionaldesign)

RQS:47

Psych

oan

alysis:78

Psycho

therap

y:10

4

AxisId

isorde

r:99

%(m

ooddisorder,4

7%;

dysthymicdisorder,

30%)

AxisIIdisorder:72%

(clin

ical

case,91%

[sco

ringin

clinical

range

onat

least

2questio

nnaires];

previoustherap

y,79%)

Psycho

analysis:

6.5years;

971sessions

Psycho

analytic

psycho

therapy:

3.9years;

180sessions

Patient:+

Therap

ist:−

Observer:+

Symptoms:

SCL-90

Personality

:IIP

Pre:+

During:

+

Post:+

Follo

w-up:

+

Netherland

s

Contin

ued

onnextpage

S. de Maat et al.


Table1

Con

tinue

d

Study

Studytype

&Resea

rch

Qua

lityScore

Trea

tmen

ts&

no.

ofsubjects

Diagn

osesin

psych

oan

alysisgroup

Duratio

n(m

eanye

ars

&sessions)

Outcome

source

Mea

sure

of

effectiven

ess

Assessm

ent

points

Country

Löffler-Stastka

etal.

(2005)62

Cohort,

prospe

ctive

RQS:

39

Psych

oan

alysis:27

Psych

otherap

y:11

AxisIdisorders:95%

(dep

ressive49%

anxiety,

39%;ea

ting,

12%)

AxisIIdisorders:100%

(dep

ressive,

25%;

bipo

lar,19

%;n

arcissistic,

17%;av

oidan

t,13%)

Psych

oan

alysis:

3.5

years;

560sessions

Psych

oanalytic

psych

otherap

y:3ye

ars(?)

Patient:+

Therap

ist:−

Observer:+

Other:−

Symptoms:SC

L-90,PST,PSD

I

Personality

:IIP,

SWAP-200

Pre:+

During:

+

Post:+

Follo

w-up:

+

Austria

Huber/Kluget

al.

(2006,2012)51,52

(Mun

ichprocess-ou

tcom

estudy)

RCT

RQS:

41

Psych

oan

alysis:35

Psych

otherap

y:31

Behaviortherapy:34

AxisI(depression

):10

0%

AxisII:

35%

Psych

oan

alysis:

3.3

years;

234sessions

Psych

oanalytic

psych

otherap

y:2.8

years;

88sessions

Patient:+

Therap

ist:−

Observer:+

Other:−

Symptoms:

SCL-90,BDI,

HDRS

Personality

:IIP,

SPC,FL

Z-G

Pre:+

During:

−Post:+

Follo

w-up:

+

German

y

Knek

tet

al.(2011

)60

Prospec

tive

cohortfor

psychoanalysis;

RCTfor

psychotherapy

RQS:

54

Psych

oan

alysis:41

Long-term

psych

oan

alytic

psycho

therap

y:12

8

Short-term

psycho

analytic

psycho

therap

y:10

1

Solutio

n-focu

sed

therap

y:97

Dep

ression:87.8%

Anxiety:

39%

PD:19.5%

(comorbidity,48.8%)

Psych

oan

alysis:

5ye

ars;

840sessions

RCT:

8months

(10sessions);

6months

(19sessions);

3ye

ars

(232sessions)

Patient:+

Therap

ist:+

Observer:+

Other:−

Symptoms:

SCL-90,HDRS,

BDI,HARS

Personality

:WAI,

GAF,PPF,

SAS-work

Pre:+

During:

−Post:+

Follo

w-up:

notye

tav

ailable

Finland

AAI,Adu

ltAtta

chmen

tInterview;BDI,BeckDep

ressionInventory;

BPD

,bipo

lardisorder;CGI-Sor

-I,Clin

ical

Globa

lIm

pression

–Severity

or–Improv

emen

t;FLZ[-G],Frageb

ogen

zurLebe

nszu

-frieden

heit[–Gesund

heit](Q

uestio

nnaire

on[H

ealth

-Related

]Life

Satisfaction;GAF,Gen

eral

Assessm

entofFu

nctioning;

HARS,

Ham

iltonAnxietyRatingScale;

HDRS,

Ham

iltonDep

ression

RatingScale;

HSR

S,Health

SicknessRatingScale;

IIP,Inventory

ofInterpersona

lProblem

s;mGAS,

mod

erated

Goa

lAtta

inmen

tScale;

MMPI,Minne

sota

Multiph

asic

Persona

lityInventory;PD,

person

ality

disorder;PP

F,Pe

rceivedPsycho

logicalF

unctioning

Scale;

PSDI,Po

sitiveSymptom

Distre

ssInde

xof

theSC

L-90

;PSK

B[-Se],Psychische

run

dsozial-kom

mun

ikativer

Befun

d[–Selbstra

ting]

(Phy

sicalan

dSo

cial

Com

mun

icationFind

ings–Self-R

eport;PS

T,po

sitivesymptom

totalof

theSC

L-90

;RCT,

rand

omized

,con

trolledtrial;RQS,

ResearchQua

lityScore;

SAS,

Social

Adjustm

entS

cale;

SAS-Work,

SASworksubscale;S

CL-90

,Symptom

Che

cklist–90

;SOC,Senseof

Coh

eren

ceScale;

SPC,S

calesof

Psycho

logicalCap

acities;S

TAI,State-TraitA

nxiety

Inventory;

SWAP,Sh

edler-Westen

Assessm

entProc

edure–20

0;WAI,WorkAbilityInde

x.aFo

urteenstudieswith

atotalof603patients.



Three studies were excluded based on language barriers,and 134 more based on full-text screening. Most importantreasons for exclusion were that the studies addressed theo-retical issues or presented case descriptions. Twenty-sevenstudies remained, of which 13 were excluded for methodo-logical or other reasons. The remaining 14 studies16,32–70

were included in the meta-analysis. Table 1 presents thestudy characteristics of the included studies. Ten studiespresented data to calculate mean ESs. Table 2 presents thecharacteristics and reasons of exclusion of the 13 excludedstudies.48(retrospective part of study),71–83 We contacted someauthors for additional data and received data from the fol-lowing: Caspar Berghout and Jolien Zevalkink; DorotheaHuber and Gunther Klug; Henriette Loffler-Stastka; RolfSandell; and Paul Knekt. Nine studies presented percen-tages of clinically improved patients and were therefore in-cluded in the secondary outcome measures.

Study CharacteristicsOf the 14 studies (total n = 603) included in our meta-analysis, 13 were prospective cohort studies, and 1 anRCT.51,52 The study of Knekt and colleagues60,84 in-cluded an RCT for three types of psychotherapy anda prospective cohort design for psychoanalysis. Thenumber of patients in the studies varied from 17 to 92.The number of sessions (for any particular patient) rangedfrom 234 to 971, and the duration of analysis from 2.5 to6.5 years. Five studies were conducted in the United States,the remainder in Europe; 5 of the 9 European studies wereconducted in Germany. Three studies16,32–47 applied across-sectional design, assessing different patient groups atpre-treatment, post-treatment, and follow-up.

The quality of the studies varied. First, the sample in-cluded only one RCT,51,52 and although some studies fol-lowed both a psychoanalysis group and a psychotherapygroup, these groups were not controlled against other treat-ment groups. Second, the measurement instruments variedconsiderably. Appendix 2 contains a list of all the instru-ments used. Third, outcome measures varied. In one study,only the therapist rated post-treatment outcome.47 In an-other study, both patients and therapists rated post-treatmentoutcome.67 In all other studies, including all follow-up mea-surements, only patient and independent ratings were in-cluded. Analyses were also performed without the studiesthat did not include independent raters (see section “Pre/PostEffectiveness of Psychoanalysis” below). In a separate sub-analysis we compared patient ratings with independent rat-ings and therapist ratings (Table 6). Fourth, six studies didnot present follow-up results, and of those studies thatdid, the follow-up periods were relatively short (between 1and 3.5 years). Fifth, treatment was not manualized in anyform, and treatment adherence was not monitored in anystudy. Systematic descriptions of treatments (mean numberof sessions, plus duration) were missing in three studies andhad to be estimated. Finally, five studies did not report on

dropouts systematically, and all studies but one providedcompleters-only outcome analyses.60 Overall intention-to-treat analyses were therefore not possible to calculate.

Diagnostic CharacteristicsTen studies presented DSM-III/IV or ICD-9/10 diagnoses.Two studies applied a form of psychoanalytic diagnosticcriteria such as the Structural Interview of Kernberg68 orneurotic or non-neurotic personality organization.53 Twostudies mentioned only that the patients were “suitable”for psychoanalysis48,63—meaning (at least in general) thata psychoanalyst, after careful clinical evaluation of a pa-tient, believed that the strengths and weaknesses of apatient’s personality structure warranted psychoanalysis.

The diagnostic characteristics of the patients in the in-cluded studies matched those found in the research ofDoidge,17,18 Caligor,19 and their colleagues. Patients suf-fered from comorbid Axis I and Axis II disorders. Depres-sive disorders (range, 27%–100%) and anxiety disorders(range, 39%–100%) were found most frequently. On aver-age, 77% of the patients in this meta-analysis suffered froma depressive disorder, and 50% from an anxiety disorder.Between 20% and 100% of all patients met criteria fora personality disorder, with an average of 47%. Other di-agnoses included eating disorders, sexual and relationaldisorders, work problems, obsessive-compulsive disorders,psychosomatic complaints, and substance abuse. Four stud-ies reported on earlier treatments, if any, of patients.16,32–46,48,60 On average, 73% of those patients had tried previoustreatments. Two studies defined the concept of a “clinical case”as patient who scored in the worst 10% clinical range on sev-eral measurement instruments.16,32–46 These two studies foundthat at baseline, 91% and 88%, respectively, of all psychoanal-ysis patients met clinical case criteria.

Refusal and Dropout RatesNine studies reported data on the number of patients thatrefused to participate in the study, did not start treat-ment, or dropped out of treatment (Table 3). Four studiesreported how many patients refused to participate in thestudy (range, 13%–40%). Dropout rates ranged from 3%to 33%.16,32–46,53,60

Pre/Post Effectiveness of PsychoanalysisTen studies provided data for pre/post analyses. Four stud-ies49,51,52,61,67 used a frequency of two to three sessions aweek, and six studies16,32–47,60,62,63 a frequency of threeor more sessions a week. The ESs and 95% CIs of thestudies are plotted in Figure 3. The mean pre/post ES(Cohen’s d)24 of psychoanalysis across all studies and all mea-surement instruments (Table 4) is 1.27 (95% CI, 1.03–1.50;p < .01), indicating a robust effect. This effect remains fairlystable when the one-study-removed method is followed.

S. de Maat et al.


Table2

Exclud

edStud

ieson

Psycho

analysisa

Study

Studytype

Trea

tmen

ts(n)a

Diagn

osis

Duratio

nbRea

sonforex

clusion

Sashin

etal.(1975)71

(BostonStudy)

Cohort,retrospec

tive

(1959–6

6)

Psych

oan

alysis:183

Hysterica

lch

arac

ter

neu

rosis(somewith

dep

ression):30%

Obsessive-co

mpulsive

neu

rosis:18%

4.2

years

Retrospec

tivestudydesign

Web

eret

al.(1985)72

Bac

hrach

etal.(1985)

(Columbia

Psych

oan

alytic

Resea

rchProject)73

Cohort,retrospec

tive

Psych

oan

alysis:235

Psych

otherap

y:138

Atleastmoderately

impairedin

thefollo

wing:

Egostrength:46%–5

5%

Social

relatio

ns:7

5%–8

5%

Workgratificatio

n:14%–3

5%

Psych

oan

alysis:2.5

years

Psych

otherap

y:0.75ye

ar

Retrospec

tivestudydesign

Web

eret

al.(1985)72

Bac

hrach

etal.(1985)73

(Columbia

Psych

oan

alytic

Resea

rchProject)

Cohort,prospec

tive

Psych

oan

alysis:36

Psych

otherap

y:29

Atleastmoderately

impairedin

thefollo

wing:

Egostrength:48%,

Social

relatio

ns:64%

Work

gratifica

tion:18%

Spec

ialsymptoms:21%

Psych

oan

alysis:4ye

ars

(720sessions)

Psych

otherap

y:2ye

ars

(120sessions)

Unclea

rhow

man

ypatientsen

ded

analysis

becausethepsycho

analytic

trainee

grad

uate&

how

man

ybec

ause

the

trea

tmen

ten

ded

Nodataav

ailable

for

calculatin

geffect

size

s

Düh

rssen(1986)74

Cohort,prospec

tive

Psych

oan

alysis:30

Psych

otherap

y:60

Unspec

ified

Unspec

ified

Trea

tmen

tnotsufficien

tlyspec

ified

Diagn

ostic

charac

teristics

ofpatientsnotsufficien

tlyspec

ified

Grossarth-M

aticek

&Ey

senck

(1990)75

Cohort,prospec

tive

Psycho

analysis:3

62&25

9Only

cance

r&

hea

rtdisea

semen

tioned

Somepatientsless

than

2ye

ars,somepatients

longe

rthan

2ye

ars

Desired

outcomewas

topreve

ntdea

thin

somatically

very

illpa

tients

Kelleret

al.(1998)76

Survey,retrospec

tive

Psych

oan

alysis:84

Psych

otherap

y:18

PD:17%

Dep

ression:46%

2.7

years

Retrospectiv

esurvey

Leuzinge

r-Bohleber

etal.

(2001,2003)77,78

Cohort,retrospec

tive

Psych

oan

alysis:207

Psych

otherap

y:194

PD:51%

Affe

ctivedisorder:27%

Psych

oan

alysis:4ye

ars

Psych

otherap

y:4ye

ars

Retrospec

tivestudydesign

Contin

ued

onnextpage



Table2

Con

tinue

d

Study

Studytype

Trea

tmen

ts(n)a

Diagn

osis

Duratio

nb

Rea

sonforex

clusion

Erle

&Goldberg(2003)48

(New

York

StudyI)

Cohort,retrospec

tive

(1973–7

7)

Psych

oan

alysis:161

Unspec

ified

(though

patientshadbeen

evaluated

assuita

ble

for

psych

oan

alytic

therap

y)

35%

had

previoustherap

y

5–6

years(840sessions)

Retrospectiv

estudydesign

Diagn

ostic

charac

teristics

ofpatientsnotsufficien

tlyspec

ified

Hartm

ann&Zep

f(20

04)79

Survey,retrospec

tive

Psych

oan

alysis:263

Psych

otherap

y:448

Dep

ression:63%

Anxiety:

36%

Gen

eral

bad

mood:42%

Pan

icdisorder:24%

Relation/sex

ual

problems:29%

Psych

osomatic

complaints:34%

2ye

ars

Retrospec

tivesurvey

Steh

le(2004)80

(DGPTstudy)

Survey,retrospec

tive

Psych

oan

alysis:354

Psych

otherap

y:227

Neu

rosis:60%

PD:31%

3ye

ars

Retrospec

tivesurvey

Rasco

net

al.(2005)81

Cohort,retrospec

tive

Psych

oan

alysis:3

Psych

otherap

y:3

Pan

icdisorder,dysthym

icdisorder,substan

ceab

use,grief

PD:100%

Psych

oan

alysis:3–6

years

Psycho

therap

y:3–

25years

Only

twopatientsin

psych

oan

alysis

Prelim

inaryresults

Brock

man

net

al.(2006)82

Cohort,prospec

tive

Psych

oan

alysis:31

DSM

-III-Rdep

ression&

anxietydisorders

3ye

ars

Largeproportionof

trea

tmen

tsstill

goingon

Puschner

etal.(2007)83

Cohort,prospec

tive

Psych

oan

alysis:11

6

Psych

otherap

y:357

Mooddisorder:48.8%

Neu

rotic

/stress/somatic

disorder:34.9%

Disordersbec

ause

of

physiologica

l/physical

factors:6.9%

PD:9.3%

Psych

oan

alysis:med

ian

length,21.4

months

(estim

ated

sessions,214)

Psych

otherap

y:med

ian

length,16months

Studyaimed

tomea

sure

courseofim

prove

men

t,notpre-posttrea

tmen

tassessmen

t.

Nopre-postoutcome

mea

suremen

ts

Inpsych

oan

alysis43%

of

trea

tmen

tsstill

ongo

ing

after2ye

ars

Inpsych

otherap

y29%

of

trea

tmen

tsstill

ongo

ing

after2ye

ars

DGPT

,German

SocietyforPsych

oan

alysis,Psych

otherap

y,Psych

osomatics,an

dDep

thPsych

ology

;PD,personality

disorder.

aThirteen

studieswith

atotalof1669patients.

bMea

nye

arsan

dsessions.

S. de Maat et al.


Heterogeneity of the overall analysis is moderate and notstatistically significant (I2 = 38.80%). The study of Huberand Klug51,52 seems an outlier, with larger ESs than theother studies. Removing this study lowers the heterogene-ity (I2 = 20.20%) and also the overall ES (1.20; 95% CI,0.98–1.41; p < .01). The study by Rudolf and colleagues67

is an outlier on the lower end of the range, with smallerESs than the other studies. Removing this study raises themean ES to 1.34 (95% CI, 1.12–1.56; p < .01). Removingboth studies that did not use independent ratings (Cogan &Porcerelli47 and Rudolf et al.),67 yields a mean ES of 1.36(95% CI, 1.11–1.60; p < .01, I2 = 29.38%).

The mean pre/post ES of psychoanalysis across all stud-ies that included only symptom instruments is 1.52 (95%CI, 1.20–1.84; p < .01), indicating a robust effect. This ef-fect remains stable when the one-study-removed method isfollowed. Heterogeneity of the overall analysis is moderateto large and statistically significant (I2 = 65.57%), and

remains so when the one-study-removed method is applied.The two outliers in this analysis are the studies of Huberand Klug (mean symptom ES = 2.27)51,52 and Rudolf(mean symptom ES = 0.87).67 Removing these two studiesdoes not change the mean ES across the remaining studiesbut lowers heterogeneity to I2 = 41.74% (not significant).

The mean pre/post ES of psychoanalysis across all stud-ies that included only personality and psychosocial func-tioning instruments is 1.08 (95% CI, 0.89–1.26, p < .01),indicating also a robust effect, albeit somewhat lowerthan the ES of studies using only symptom measures. TheESs remain similar when the one-study-removed methodis applied. Heterogeneity of the overall analysis is very low(I2 = 8.76%) suggesting a very similar outcome across studies.

Sub-analyses showed that the difference between higher-quality studies and lower-quality studies was statisticallysignificant (p = .01), with the former showing higher ESs(the quality score of studies was not determined by the

Table 3

Refusal and Dropout Rates with Psychoanalysis

Study Refused to participate in study Did not start therapy Dropout from therapy

Kantrowitz et al. (1975)53 23% 0%(6% did not get selected bya psychoanalytic trainee)

3% (6% dropped out fromstudy, but not treatment)

Wallerstein (1986)68 Unknown Unknown 27% changed to psychoanalyticpsychotherapy

Rudolf et al. (1994)67 Unknown Unknown 8%

von Rad et al. (1998)64 Unknown Unknown Unknown

Sandell et al. (2000)16 40% (total for psychoanalysisand psychotherapy)

3% (total for psychoanalysisand psychotherapy)

Unknown

Luborsky et al. (2001)63 Unknown Unknown Only completers

Erle & Goldberg (2003)48 Unknown 6 not reported forconfidentiality reasons

33%(unsatisfactory ending)

Cogan & Porcerelli (2005)47 Unknown Unknown Only completers

Leichsenring et al. (2005)61 Unknown Unknown Only completers

Grande et al. (2006)49 30% (total for psychoanalysisand psychotherapy)

0% 13.5%(another 13.5% dropped out

from the study, but nottreatment)

Berghout /Zevalkink et al.(2006–10, 2012)32–46

21% refused; 14% did notrespond (total for psychoanalysis

and psychotherapy)

6.4% did not start or dropped out (total for psychoanalysisand psychotherapy)

Löffler-Stastka et al. (2008)62 Unknown 0% 33%

Huber/Klug et al. (2006, 2012)51,52 21% (31 of 150 screened)did not fulfill the inclusion

criteria or were not motivatedto enter into therapy

16% did not start 0% (6% dropped out fromfollow-up phase)

Knekt et al. (2011)60 13% 2% (because of life situations) 12% (7% life situations,5% disappointment

in treatment)



magnitude of the ESs). No difference was found betweenstudies using a cross-sectional design and prospective co-hort studies (p = .14). We also found no significant differ-ences in effects between studies from Europe and studiesperformed in the United States (p = .53). Finally, we foundno differences between the four studies49,51,52,61,67 with alower session frequency (two to three sessions a week;mean number of sessions across studies = 266) and the sixstudies16,32–47,60,62,63 with a higher session frequency (threeto five sessions a week; mean number of sessions = 793)(p = .41 for all instruments’ p = .52 for symptoms instru-ments; p = .73 for personality and psychosocial functioninginstruments).

Three studies used specific depression instruments.32–46,51,52,60 The mean ES was 1.85 (95% CI, 1.13–2.58; p < .01).Heterogeneity in this sub-analysis was high (I2 = 78.97%).

Heterogeneity in the sub-analyses seemed the highestamong the group of studies using lower session frequency(all German studies). This finding could be explained bythe contrast between the studies of Leichsenring,61 Huberand Klug,51,52 and Grande and colleagues,49 on the onehand, and the study of Rudolf,67 on the other. Mean ESs ofthese studies (using all instruments) were 1.65, 1.86, 1.38,and 0.87, respectively. The first three studies mentioned,which are more recently performed and use more diverse, in-ternational measurement instruments (by contrast, Rudolf’sstudy uses only a German measurement instrument), consis-tently present higher ESs. It is not clear, however, how thesedifferences in time and instruments affect ES.

Pre/Follow-Up Effectiveness of PsychoanalysisOnly five studies provided data regarding follow-up analy-ses (Table 5). The mean pre/follow-up ES (Cohen’s d)24

of psychoanalysis across all these studies and all measure-ment instruments is 1.46 (95% CI, 1.08–1.83; p < .01; seeFigure 4), indicating that the effect of psychoanalysis atfollow-up remains stable. This effect remains fairly stablewhen the one-study-removed method is followed. Hetero-geneity of the overall analysis is moderate but not statis-tically significant (I2 = 50.56%). Removing studies doessomewhat lower the heterogeneity, with the lowest het-erogeneity (I2 = 25.75%) resulting from the removal of

the study by Berghout, Zevalkink, and colleagues.32–46

This study has the lowest mean ES (0.90) of the follow-upstudies; the other studies’ ESs were 1.20 (Sandell et al.),16

1.43 (Grande et al.),49 1.79 (Leichsenring et al.),61 and1.97 (Huber/Klug et al.).51,52 Removing the Berghout andZevalkink study elevates the mean ES across studies to 1.59(95% CI, 1.25–1.93; p < .01).

The mean pre/follow-up ES of psychoanalysis acrossall studies that included only symptom instruments is1.65 (95% CI, 1.24–2.06, p < .01), indicating that the ef-fect of psychoanalysis at symptom level is stable or even en-larged at follow-up. The mean pre/follow-up ES remainssimilar when the one-study-removed method is followed.Heterogeneity of the overall analysis is moderate (I2 =56.89%) but not statistically significant. Removing theHuber and Klug study51,52 lowers heterogeneity consider-ably (I2 = 33.65%) and leaves the mean ES at 1.50 (95%CI, 1.12–1.87; p < .01). The Huber and Klug study is anoutlier with the highest mean ES for symptom instruments(2.24); the other studies in this category have ESs of 1.25(Berghout/Zevalkink et al.),32–46 1.58 (Grande et al.),49

2.03 (Leichsenring et al.),61 and 1.17 (Sandell et al.).16

The mean pre/follow-up ES of psychoanalysis across allstudies that include only personality and psychosocial func-tioning instruments is 1.31 (95% CI, 1.00–1.62; p < .01),again indicating that the effects of psychoanalysis arestable at follow-up. The mean ES remains similar with theone-study-removed method. Heterogeneity of the overallanalysis is low (I2 = 29.55%). The study of Berghout andZevalkink32–46 seems an outlier; removing this study lowersheterogeneity to zero and raises the mean ES to 1.43 (95%CI, 1.15–1.72; p < .01). This study has the lowest mean ESacross personality and psychosocial functioning instru-ments (0.75); the other studies in this category had ESs of1.29 (Grande et al.),49 1.69 (Huber/Klug et al.),51,52 1.54(Leichsenring et al.),61 and 1.21 (Sandell et al.).16

Sub-analyses showed that at follow-up there were nodifferences in effects between studies that were consideredhigher in quality and studies lower in quality (p = .39).There was a significant difference at follow-up, however,between the studies with cross-sectional design and theother studies, with the former reporting lower mean ESs

Figure 3. Meta-analysis pre/post effect sizes, overall.

S. de Maat et al.


Table 4

Meta-analyses of Studies Examining the Pre- to Post-treatment Change with Psychoanalysis

n d 95% CI Z Q I2 p

Pre/post outcomes for psychoanalysis: All instruments

All studies 10 1.27 1.03–1.50 10.00** 14.71 38.80

One study removed

Rudolf et al. (1994)67 9 1.34 1.12–1.56 11.79** 10.13 21.05

Sandell et al. (2000)16 9 1.30 1.05–1.56 10.12** 13.46a 40.54

Luborsky et al. (2001)63 9 1.29 1.04–1.54 10.03** 14.28 43.99

Cogan & Porcerelli (2005)47 9 1.27 1.02–1.53 9.68** 14.67 45.48

Leichsenring et al. (2005)61 9 1.22 0.98–1.46 9.90** 12.48 35.90

Löffler-Stastka et al. (2005)62 9 1.27 1.02–1.52 9.97** 14.69 45.55

Grande et al. (2006)49 9 1.26 0.99–1.52 9.44** 14.51 44.86

Huber/Klug et al. (2006,2012)51,52

9 1.20 0.98–1.41 10.97** 10.03 20.20†

Berghout/Zevalkink et al.(2006–10, 2012)32–46

9 1.30 1.05–1.55 10.23** 13.47 40.62

Knekt et al. (2011)60 9 1.22 0.98–1.47 9.80** 12.58 36.41

Pre/post outcomes for psychoanalysis: Symptom instruments

All studies 10 1.52 1.20–1.84 9.33** 26.12** 65.55

One study removed

Rudolf et al. (1994)67 9 1.61 1.30–1.91 10.35** 17.54** 54.40†

Sandell et al. (2000)16 9 1.58 1.25–1.92 9.17** 22.71** 64.77

Luborsky et al. (2001)63 9 1.57 1.22–1.91 8.99** 24.81** 67.76

Cogan & Porcerelli (2005)47 9 1.49 1.15–1.84 8.44** 25.06** 68.08

Leichsenring et al. (2005)61 9 1.46 1.13–1.79 8.68** 22.02** 63.67

Löffler-Stastka et al. (2005)62 9 1.48 1.15–1.81 8.81** 24.69** 67.60

Grande et al. (2006)49 9 1.52 1.16–1.88 8.32** 26.07** 69.31

Huber/Klug et al. (2006,2012)51,52

9 1.43 1.13–1.73 9.32** 18.55** 56.87


9 1.56 1.21–1.91 8.69** 25.13** 68.16

Knekt et al. (2011)60 9 1.50 1.14–1.85 8.26** 25.05** 68.07

Pre/post outcomes for psychoanalysis: Personality instruments

All studies 10 1.08 0.89–1.26 11.50** 9.86 8.76

One study removed

Rudolf et al. (1994)67 9 1.15 0.96–1.35 11.84** 6.06 0.00

Sandell et al. (2000)16 9 1.09 0.89–1.30 10.40** 9.67 17.25

Luborsky et al. (2001)63 9 1.09 0.89–1.29 10.62** 9.77 18.08

Continued on next page



Table 4

Continued

n d 95% CI Z Q I2 p

Pre/post outcomes for psychoanalysis: Personality instruments

Cogan & Porcerelli (2005)47 9 1.08 0.88–1.29 10.39** 9.86 18.85


Löffler-Stastka et al. (2005)62 9 1.10 0.91–1.29 11.35** 8.97 10.78

Grande et al. (2006)49 9 1.06 0.86–1.27 10.21** 9.55 16.19

Huber/Klug et al.(2006, 2012)51,52

9 1.03 0.85–1.22 10.97** 7.90 0.00


9 1.10 0.91–1.30 10.92** 9.18 12.85

Knekt et al. (2011)60 9 1.02 0.84–1.21 10.80** 7.20 0.00

Subanalyses: All studies, all instruments

Study qualityb 10 .01

Lower end 5 0.99 0.72–1.25 7.37** 1.21 0.00

Higher end 5 1.49 1.20–1.79 9.96** 5.73 30.15

Study designc 10 .14

Cross-sectional 3 1.03 0.70–1.36 6.15** 0.40 0.00

Prospective 7 1.37 1.06–1.68 8.76** 11.68 48.61

Continentd 10 .53

Europe 8 1.28 1.09–1.47 12.95** 14.23* 50.80

USA 2 1.13 0.65–1.60 4.66** 0.13 0.00

Sessionse

Pre/post all instruments 10 .41

2–3 sessions/week(mean = 266 sessions)

4 1.40 0.93–1.87 5.83** 9.77* 0.00


6 1.18 1.01–1.45 10.94** 4.14 0.00

Pre/post symptom instruments 10 .52


4 1.65 1.00–2.31 4.97** 17.42* 82.78


6 1.42 1.09–1.75 8.40** 8.16 38.72

Pre/post personality instruments 10 .73


4 1.13 0.78–1.47 6.42** 5.72 47.55


6 1.05 0.81–1.30 8.38** 4.07 0.00


S. de Maat et al.


(p = .02). Since all studies reporting follow-up were con-ducted in Europe, no comparison could be made betweenEuropean and American studies in this respect. We alsofound two significant differences (overall effect and symp-tom change) between the (German) studies with a lowermean number of sessions (mean number of sessions acrossstudies = 266) and those with a higher mean number of ses-sions (mean number of sessions across studies = 810), withthe latter reporting lower ESs. The difference between thesestudies for personality and psychosocial functioning changewas a trend finding in the same direction (p = .07).

Finally, we found a significant difference between stud-ies with follow-up periods up to one year and studies withlonger follow-up periods (p < .01), indicating lower ESswith studies that included longer follow-up periods. Het-erogeneity in the statistically significant sub-analyses wasvery low to zero, indicating that these follow-up periodswere relevant sources of heterogeneity in the main analyses.The two studies using depression instruments showed alarge mean ES at follow-up (1.81; 95% CI, 0.33–3.28),again presenting high heterogeneity, which was discussedearlier.32–46,51,52

Comparison of Psychoanalysis Posttest Means andMeans of Nonclinical Norm GroupsSeven studies16,32–46,51,52,60–62 could be used to compareposttest means of psychoanalysis against means of nonclin-ical groups. Table 6 presents between-group ESs.

Generally, the posttest means of psychoanalysis do notdiffer from the means presented by nonclinical groups.Between-group ESs are small and not statistically significant.Three subscales of the Minnesota Multiphasic Personality

Inventory in the Berghout and Zevalkink study show thatthe posttest means of patients who underwent psychoanalysisare still more elevated than those of nonclinical groups.

Ratings of Therapists Versus Patients Versus ObserversWe compared all patient-rated outcomes with therapist-ratedoutcomes and with observer-rated outcomes (Table 7). Post-treatment and follow-up measurements were taken together.We found that therapist-rated instruments yielded the low-est ESs and that observer-rated instruments yielded thehighest, with patient ratings falling in between. Only thedifference between the ratings of therapists (lowest ratings)and observers (highest ratings) was statistically significant.

Clinically Significant ChangeOur secondary outcome was clinically significant change,indicating how many patients underwent a change thatwas considered clinically relevant. The criteria are pre-sented in Tables 8a and 8b. The former presents the re-sults measured with symptom or general instruments, andthe latter shows the results measured with personalityinstruments.

At treatment termination an average of 77% of thepatients achieved scores under a clinically defined cutoffscore or criterion (indicating they were falling in the rangeof a nonclinical population) of a symptom or general in-strument, 48% more than the number of patients scoringunder those cutoff scores at baseline. At follow-up an aver-age of 75% achieved that status. For personality and psy-chosocial functioning instruments, the results indicate thatan average of 62% of the patients achieved scores under aclinically defined cutoff score or criterion (indicating that

Table 4

Continued

Sessionse

n d 95% CI Z Q I2 p

Only depression instrumentsf 3 1.85 1.13–2.58 5.02** 9.51** 78.97a Italic numbers indicate a nonsignificant trend (p < .10).b Low ≤ 40 Research Quality Score: Cogan & Porcerelli (2005),47 Löffler-Stastka et al. (2005),62 Luborsky et al. (2001),63 Rudolf et al. (1994),67 Sandell et al.(2000);16 High > 40 Research Quality Score: Berghout/Zevalkink et al. (2006–10, 2012),32–46 Grande et al. (2006),49 Huber/Klug et al. (2006, 2012),51,52 Knektet al. (2011),60 Leichsenring et al. (2005).61c Cross-sectional: Berghout /Zevalkink et al. (2006–10, 2012),32–46 Cogan & Porcerelli (2005),47 Sandell et al. (2000);16 prospective: Grande et al. (2006),49

Huber/Klug et al. (2006, 2012),51,52 Knekt et al. (2011),60 Leichsenring et al. (2005),61 Löffler-Stastka et al. (2005),62 Luborsky et al. (2001),63 Rudolf et al. (1994).67

d Europe: Berghout /Zevalkink et al. (2006–10, 2012),32–46 Grande et al. (2006),49 Huber/Klug et al. (2006, 2012),51,52 Knekt et al. (2011),60 Leichsenringet al. (2005),61 Löffler-Stastka et al. (2005),62 Rudolf et al. (1994),67 Sandell et al. (2000);16 USA: Cogan & Porcerelli (2005),47 Luborsky et al. (2001).63e >350 sessions: Berghout /Zevalkink et al. (2006–10, 2012),32–46 Cogan & Porcerelli (2005),47 Knekt et al. (2011),60 Löffler-Stastka et al. (2005),62 Sandellet al. (2000),16 Luborsky et al. (2001);63 ≤350 sessions: Grande et al. (2006),49 Huber/Klug et al. (2006, 2012),51,52 Leichsenring et al. (2005),61 Rudolfet al.(1994).67

f Berghout/Zevalkink et al. (2006–10, 2012),32–46 Huber/Klug et al. (2006, 2012),51,52 Knekt et al. (2011).60

* p < .05

** p < .01† Indicates lowest heterogeneity.



Table 5

Meta-analyses of Studies Examining the Pre- to Follow-Up Treatment Change with Psychoanalysis

n D 95% CI Z Q I2 p

Pre/post outcome for psychoanalysis: All instruments

All studies 5 1.46 1.08–1.83 7.60** 8.09a 50.56

One study removed

Sandell et al. (2000)16 4 1.52 1.07–1.98 6.53** 7.14 57.99


Grande et al. (2006)49 4 1.46 0.97–1.95 5.86** 8.08* 62.88

Huber/Klug et al. (2006, 2012)51,52 4 1.33 0.97–1.68 7.27** 4.37 31.29

Berghout/Zevalkink et al. (2006–10, 2012)32–46 4 1.59 1.25–1.93 9.13** 4.04 25.75†

Pre/post outcome for psychoanalysis: Symptom instruments

All studies 5 1.65 1.24–2.06 7.82** 9.28 56.89

One study removed

Sandell et al. (2000)16 4 1.77 1.34–2.21 7.82** 6.07 50.58


Grande et al. (2006)49 4 1.67 1.13–2.21 6.08** 9.22* 67.47

Huber/Klug et al. (2006, 2012)51,52 4 1.50 1.12–1.87 7.86** 4.52 33.65†

Berghout/Zevalkink et al. (2006–10, 2012)32–46 4 1.75 1.27–2.22 7.24** 7.41 59.50

Pre/post outcome for psychoanalysis: Personality & psychosocial functioning

All studies 5 1.31 1.00–1.62 8.29** 5.68 29.55

One study removed

Sandell et al. (2000)16 4 1.33 0.94–1.72 6.62** 5.53 45.75


Grande et al. (2006)49 4 1.31 0.91–1.71 6.37** 5.67 47.06

Huber/Klug et al. (2006, 2012)51,52 4 1.21 0.89–1.52 5.57** 3.41 12.11

Berghout/Zevalkink et al. (2006–10, 2012)32–46 4 1.43 1.15–1.72 9.82** 1.79 0.00†

Subanalyses: All studies, all instruments

Study qualityb 5 .39

Lower end 1 1.20 0.62–1.78 4.03** 0.00 0.00

Higher end 4 1.52 1.07–1.98 6.53** 7.14 57.99

Study designc 5 .02

Cross-sectional 2 1.05 0.64–1.47 4.95** 0.48 0.00

Prospective 3 1.72 1.38–2.06 9.91** 1.72 0.00

Continentd 5 NA

Europe 5 1.46 1.08–1.83 7.60** 8.09 50.56

USA 0


S. de Maat et al.


they fell in the range of a nonclinical population), 34%morethan the number of patients scoring under those cutoff scoresat baseline. At follow-up, an average of 65% achieved sucha status.

Publication BiasBased on the absence of significant differences betweenthe adjusted mean ESs (and 95% CI) and the observedvalues for any of the main comparisons, we failed to find

Table 5

Continued

n D 95% CI Z Q I2 p

Sessionse

Pre/post all instruments 5 .02

2–3 sessions/week (mean = 266 sessions) 3 1.72 1.38–2.06 9.91** 1.72 0.00


Pre/post symptom instruments 5 .01



Pre/post personality instruments 5 .07



Duration of follow-upf 5 .02

Follow-up > 1 year 2 1.05 0.64–1.47 4.95** 0.48 0.00

Follow-up ≤ 1 year 3 1.72 1.38–2.06 9.91** 1.72 0.00

Only depression instrumentsg 2 1.81 0.33–3.28 2.40** 11.22** 91.09

NA, not available.a Italic numbers indicate a nonsignificant trend (p < .10)b Low ≤ 40 Research Quality Score: Sandell et al. (2000)16; High > 40 Research Quality Score: Berghout/Zevalkink et al. (2006–10, 2012),32–46 Grandeet al. (2006),49 Huber /Klug et al. (2006, 2012),51,52 Leichsenring et al. (2005).61c Berghout/Zevalkink et al. (2006–10, 2012),32–46 Sandell et al. (2000);16 prospective: Grande et al. (2006),49 Huber/Klug et al. (2006, 2012),51,52 Leichsenringet al. (2005).61d Berghout /Zevalkink et al. (2006–10, 2012),32–46 Grande et al. (2006),49 Huber/Klug et al. (2006, 2012),51,52 Leichsenring et al. (2005),61 Sandell et al.(2000).16

e >350 sessions: Berghout/Zevalkink et al. (2006–10, 2012),32–46 Sandell et al. (2000).16 ≤350 sessions: Grande et al. (2006),49 Huber/Klug et al. (2006,2012),51,52 Leichsenring et al. (2005).61f Follow-up ≤ 1 year: Grande et al. (2006),49 Huber/Klug et al. (2006, 2012),51,52 Leichsenring et al. (2005).61 Follow-up > 1 year: Berghout/Zevalkink et al.(2006–10, 2012),32–46 Sandell et al. (2000).16

g Berghout /Zevalkink et al. (2006–10, 2012),32–46 Huber/Klug et al. (2006, 2012).51,52

* p <.05

** p <.01† Indicates lowest heterogeneity.

Figure 4. Meta-analysis pre/follow-up effect sizes, overall.



Table 6

Comparison of Posttest Means of Psychoanalysis and Means of Nonclinical Norm Groups

Between- group ESa p 95% CI Z

SCL-90 Dutch norm

Nonclinical vs. Berghout/Zevalkink et al.(2006–10, 2012)32–46

0.056 .782 −0.338 to 0.450 0.277

SCL-90 Finnish norm

Nonclinical vs. Knekt et al. (2008)84 0.144 .418 −0.204 to 0.492 0.809

SCL-90 Swedish norm

Nonclinical vs. Sandell et al. (2000)16 0.250 .141 −0.083 to 0.582 1.472

SCL-90 German norm

Nonclinical vs. Grande/Rudolf et al.(2006, 2007)49,50

0.103 .571 −0.252 to 0.457 0.567

Nonclinical vs. Huber/Klug et al. (2006, 2012)51,52 0.154 .365 −0.180 to 0.488 0.905

Nonclinical vs. Leichsenring et al. (2005)61 0.051 .760 −0.278 to 0.381 0.306

Nonclinical vs. Löffler-Stastka et al. (2005)62 −0.103 .734 −0.695 to 0.490 −0.340

BDI Dutch norm


0.016 .938 −0.386 to 0.418 0.078

BDI German norm

Nonclinical vs. Huber/Klug et al. (2006, 2012)51,52 −0.152 .395 −0.501 to 0.198 −0.851

IIP Dutch norm


0.346 .089 −0.053 to 0.744 1.700

IIP German norm

Nonclinical vs. Huber/Klug et al. (2006, 2012)51,52 −0.410 .017 −0.746 to −0.074b −2.394

Nonclinical vs. Leichsenring et al. (2005)61 −0.009 .956 −0.340 to 0.322 −0.055

Nonclinical vs. Löffler-Stastka et al. (2005)62 0.308 .310 −0.286 to 0.901 1.016

STAI Dutch norm

Nonclinical vs. Berghout /Zevalkink et al.(2006–10, 2012)32–46

0.084 .684 −0.320 to 0.489 0.407

MMPI

Nonclinical vs. Berghout/Zevalkink et al.(2006–10, 2012)32–46(scale 2)

0.318 .116 −0.078 to 0.714 0.116

Nonclinical vs. Berghout/Zevalkink et al.(2006–10, 2012)32–46 (scale 4)

1.030 .000 0.632 to 1.428b 5.073


0.631 .002 0.234 to 1.027b 3.117


0.500 .013 0.103 to 0.896b 2.471


0.030 .883 −0.366 to 0.426 0.148

BDI, Beck Depression Inventory; IIP, Inventory of Interpersonal Problems; MMPI, Minnesota Multiphasic Personality Inventory; SCL-90, Symptom Checklist–90;STAI, State-Trait Anxiety Inventory.a Negative d’s indicate that psychoanalysis performs better than norm group.b Significant difference.

S. de Maat et al.


any indication of publication bias in this meta-analysis(Table 9). When looking at the number of trimmed studies,some evidence for publication bias was found. The meanES for publication bias of all studies based on only symp-tom instruments was lower at post-treatment after ad-justing for publication bias (Cohen’s d = 1.36; 95% CI,1.03–1.65). The number of trimmed studies was two, indi-cating that (based on the funnel plot that shows the spread-ing of studies and their ESs) due to publication bias, twostudies in the field of psychoanalysis might be missing. Thispublication bias refers to the possibility of studies not beingpublished (perhaps due to study quality or minor results).However, the adjusted value represents a small differencefrom the 1.52 that we found in this meta-analysis.

SUMMARY AND DISCUSSIONWe found that psychoanalysis yields substantial pre/postand pre/follow-up change for patients presenting withlong-standing, complex mental disorders—most often acombination of DSM-IV mood or anxiety disorders andpersonality disorders. At treatment termination, the meanpre/post ES was 1.27 for all outcome instruments taken to-gether, 1.52 for symptom instruments, and 1.08 for per-sonality and social functioning outcomes, all indicatingsubstantial pre/post change. At follow-up the mean pre/follow-up ESs 1.46, 1.65, 1.31, respectively, indicating astable effect. The majority of patients (62%–76%) achieveda clinically significant change, and these figures seemed sta-ble at follow-up. Posttest means showed that after theirtreatment, psychoanalysis patients mostly fall in the rangeof nonclinical groups.

As our findings are based on pre/post studies, the effectsof psychoanalysis cannot be compared to the effects of

possible alternative treatments; consequently, firm conclu-sions about effectiveness are not possible here.

The dropout rate (between 3% and 33%) did not seemhigher in psychoanalysis than in short-term psychothera-pies (e.g., 47% in Pampallona et al.85 and 37%–54% inCasacalenda et al.),86 which is notable in view of the lengthof treatment. Two of the three studies with the highest drop-out rates involved more severe pathology, with 100% of thepatients presenting with a personality disorder.62,64–66,87

Overall, the heterogeneity in the analyses was moderate,indicating that there are probably systematic differencesbetween the outcomes. The heterogeneity might be influ-enced by the different measurement instruments used andby differences in patient populations and the treatmentsused. For instance, 72% of the patients in the Berghout andZevalkink study32–46 met criteria for personality disorders,and these patients showed lower ESs on depression instru-ments. By contrast, 34% of the patients in the Huber andKlug study51,52 and 19.50% in the Knekt60 study had person-ality disorders, and both groups of patients showed higherESs on depression instruments. Although we can reach nodefinitive conclusions regarding the relationship betweenpersonality disorders and depression outcomes, Newton-Howes and colleagues88 have shown in a meta-analysis thatthe presence of personality disorders reduces the effect oftreatment outcomes for depression.

It could also be suggested, however, that heterogene-ity was mainly influenced by the differences between thestudies with lower session frequency—all performed inGermany—and those with higher session frequency. TheGerman studies were characterized by better study quality,lower prevalence of patients with personality disorders, and,on average, fewer sessions and higher ESs. In Germany, insur-ance coverage for psychoanalysis is limited to 300 sessions.

Table 7

Therapist Versus Patient Versus Observer Ratings

d 95% CI Z p

Psychoanalysis; all studies, all instruments, all measurement moments

Therapist vs. patient .119

Therapist 0.92 0.51–1.33 4.42**

Patient 1.30 1.06–1.53 10.85**

Therapist vs. observer .021*

Therapist 0.92 0.51–1.33 4.42**

Observer 1.65 1.18–2.11 6.96**

Patient vs. observer .182

Patient 1.30 1.06–1.53 10.85**

Observer 1.65 1.18–2.11 6.96**

* p < .05** p < .01



How this influences treatment results or indications remainsunclear. More research is needed to shed further light on ourfindings; for example, dose-response studies would be espe-cially useful.

Sub-analyses at treatment termination indicate that someheterogeneity is present even among the German studies.Rudolf’s study,67 for example, seems to be an outlier within

that group; it has considerably lower ESs than the other,more recent studies. A partial explanation could that thestudy used different measurement instruments; whereasthe Rudolf study used only one (German) questionnaire(Psychischer und sozial-kommunikativer Befund), whereasthe other studies used various, more internationally em-ployed instruments such as the Beck Depression Inventory,

Table 8a

Significant Clinical Change on Symptom and General Instruments in Psychoanalysis Studies

Study n Criterion Pre Post Follow-upPre/postdifference

Pre/follow-updifference

Wallerstein (1986)68 22 Global improvement (therapist) NA NA 59% NA NA

von Rad et al. (1998)64 36 Good improvement of symptoms(therapist & observer)

NA 57% 30% NA NA

Good attainment of therapy goals(patient & observer)

NA NA 72% NA NA

Sandell et al. (2000)16 74 No “clinical case” (patient) 12% NA 70% NA 58%

Luborsky et al. (2001)63 17 Moderate to much improvementon two symptom scales

(observer)

NA 65% NA NA NA

Erle & Goldberg(2003)48

92 Good to excellent improvementon CGI-I (therapist)

NA 66% NA NA NA

Rudolf et al. (2004)50 44 Improved on global scale(therapist)

NA 64% NA NA NA

Improved somatic problems(therapist)

NA 62% NA NA NA

Improved mental problems(therapist)

NA 82% NA NA NA

Leichsenring et al.(2005)61

36 Clinical significant change onSCL (patient)

NA 77% 80% NA NA

Target problems (therapist) NA 84% NA NA NA

Grande et al. (2006)49 27 Significant improvement on SCL& shift from dysfunctional to

functional (patient)

NA 61% NA NA NA

Huber /Klug et al.(2006, 2012)51,52

35 No F32 diagnosis (observer) 52% 97% 97% 45% 45%

No F33 diagnosis (observer) 43% 94% 91% 51% 48%

No double depression (observer) 40% 94% 97% 54% 57%

Knekt (2008)84 41 No Axis I disorder (observer) 0% 49% NA 49% NA

Berghout/Zevalkinketal.(2006–10, 2012)32–46

78 Below clinical cutoff score onSCL-90 (patient)

36% 90% 82% 54% 46%

Below clinical cutoff score onBDI (patient)

36% 84% 86% 48% 50%

Below clinical cutoff score onSTAI (patient)

24% 77% 86% 53% 62%

Mean 29% 77% 75% 48% 46%

BDI, Beck Depression Inventory; CGI-I, Clinical Global Impression–Improvement; F32, depression, single-episode (ICD-10); F33, depression, recurrent(ICD-10); NA, not available; SCL, Symptom Checklist; STAI, State-Trait Anxiety Inventory.

S. de Maat et al.


Hamilton Depression Rating Scale, Inventory of Interper-sonal Problems, and Symptom Checklist–90. In addition, theRudolf study, dating from 1994, is the oldest of the Germanstudies. Advances in the discipline could potentially havecontributed to the differences seen in the more recent studies.That said, the differences remain, without further investiga-tion, largely unexplained.

For personality measurements at treatment termina-tion, heterogeneity was almost zero, indicating that hetero-geneity resulted from differences in the effects of symptomchange across studies. At follow-up, heterogeneity was alsovery low to zero in the statistically significant sub-analyses.

Publication bias seems fairly low in our study. ESs com-puted after the trim-and-fill method did not differ signifi-cantly from the mean ESs found in the meta-analysis. Dueto the small number of studies, however, calculations ofpublication bias must be interpreted cautiously.

Nine of the 14 studies encompassed a long-term psycho-analytic psychotherapy condition in addition to psychoanal-ysis. In this article we restricted ourselves to the pre/postfindings of psychoanalysis studies. The question of whetherthe results of psychoanalysis and LTPP in nonrandomizedstudies can be compared is a complicated one. One study51,52

did randomize patients to psychoanalysis or LTPP. The

Table 8b

Clinically Significant Change in Personality and Psychosocial Functioning Instruments in Psychoanalysis Studies

Study n Criterion Pre Post Follow-upPre/postdifference

Pre/follow-updifference

Kantrowitz et al.(1975, 1986, 1987,1990)53–59

22 Positive to complete success inaffect availability (therapist)

NA NA 86% NA NA

Improved reality testing(therapist)

NA NA 73% NA NA

Sandell et al.(2000)16

74 No “clinical case” (patient &observer)

12% NA 70% NA 58%

Rudolf et al.(2004)50

44 Improved on relationalproblems (therapist)

NA 61% NA NA NA

Leichsenring et al.(2005)61

36 Improved on interpersonalcapacities (therapist)

NA 84% NA NA NA

Improved on capacity to work(therapist)

NA 53% NA NA NA

Improved on capacity to enjoy(therapist)

NA 53% NA NA NA

Dealing with conflicts(therapist)

NA 79% NA NA NA

Grande et al.(2006)49

27 Significant improvement on IIPand shift from dysfunctional to

functional (patient)

NA 47% 52% NA NA

Berghout/Zevalkinket al. (2006–10,2012)32–46

78 Below clinical cutoff score onIIP (patient)

28% 71% 64% 43% 56%

Below clinical cutoff on MMPI(scale 2) (patient)

32% 74% 73% 42% 41%


16% 42% 50% 26% 34%


20% 61% 59% 41% 39%


36% 61% 59% 25% 23%


44% 61% 68% 17% 24%

Mean 28% 62% 65% 34% 37%

IIP, Inventory of Interpersonal Problems; MMPI, Minnesota Multiphasic Personality Inventory; NA, not available.



authors found that at follow-up, psychoanalysis performedbetter than LTPP on personality measures (Inventory of In-terpersonal Problems and Scale of Psychological Capacities)and on a goal attainment scale.

Finally, we found that in this meta-analysis, therapistratings were the lowest, that observer ratings were thehighest, and that patient ratings fell in between (a possiblycounterintuitive result in that one might expect therapiststo rate their own work higher than independent observers).There are pros and cons, of course, for utilizing the ratingsprovided by these three different groups. On the one hand,independent observers have less vested interest in the treat-ment and might therefore be less biased in judging results.On the other hand, patients and therapists have much moreexposure to the actual evidence than independent obser-vers. The literature is not in agreement on the question ofwhether patients and therapists might overestimate therapysuccess. In analyzing the findings of the Menninger Founda-tion’s psychotherapy research project, Harty and Horwitz70

found that both therapists (65%) and patients (54%) ratedtherapy success higher than independent judges (38%).Other studies have found, though, that self-reports presentmore modest results than observer ratings.76,78,89,90

LimitationsSeveral limitations of our meta-analysis caution againstoverinterpreting the results. The most important limitationis the use of pretest/posttest analyses; all studies, except forone, were pre/post cohort studies, lacking (randomized)control groups. In evidence-based medicine’s hierarchy ofevidence, RCTs present strong scientific evidence, whereasthe evidence from pre/post cohort studies is only moderate.The importance of control groups is made clear by Smitand colleagues91 in their recent meta-analysis of LTPP.Their subgroup analysis of the domain’s “target problemsshowed that LTPP did significantly better when comparedto control treatments without a specialized psychotherapy

component, but not when compared to various specializedpsychotherapy control treatments.” Considered from thispoint of view, the evidence for the effects of psychoanalysiscannot be more than of moderate strength.

Several researchers have pointed to the difficulties andlimitations of RCTs in the field of intensive, long-term treat-ments, of which psychoanalysis is paradigmatic.64,92,93

de Jonghe and colleagues20 brought attention to the limitedfeasibility of RCTs because of the restricted acceptability ofthe control conditions—especially, but not exclusively, inpsychoanalysis. They argue that randomization to the mostinformative control conditions (waiting list, placebo, andno treatment), coupled with the extended length of the treat-ment period, renders RCTs unacceptable for patients. Mostpatients considering a psychoanalytic treatment have previ-ously tried therapies with a much lower frequency or dura-tion with no success, and no evidence-based therapies withfrequency of sessions and duration comparable to psycho-analysis are available yet to serve as additional conditionsin an RCT. Patients are not likely to accept the risk of beingallocated by chance to a control condition that they knowall too well.

Notwithstanding such concerns, some RCTs have beenundertaken. Huber and Klug51,52 succeeded in randomizingpatients with depressive disorders to two fairly complicatedrandomization rounds (G. Klug, written communication).In the first phase, patients were randomized between psycho-analysis and psychodynamic psychotherapy. A few yearslater a third group was added—for cognitive-behavioraltherapy (CBT). In this second phase the randomizationboard considered but ultimately rejected the possibility ofrandomly allocating new patients to the three experimen-tal groups; instead, most patients were allocated to thecognitive-behavioral condition, bring it up to the samenumber as the other two groups. As psychoanalysis inthis RCTaveraged two sessions a week, the relatively smalldifference between this treatment and the other condition

Table 9

Publication Biases of All Studies Examining the Pre/Post and Pre/Follow-up Treatment Change with Psychoanalysis

d 95% CI Trimmed studies (n)

Psychoanalysis pre/post, all studies (n = 10)

All instruments 1.27 1.03–1.50 0

Symptom instruments 1.36 1.06–1.71 2

Personality instruments 1.10 0.92–1.28 1

Psychoanalysis pre/follow-up, all studies (n = 5)

All instruments 1.46 1.08–1.83 0

Symptom instruments 1.65 1.24–2.06 0

Personality instruments 1.31 1.00–1.62 0

S. de Maat et al.


(psychodynamic therapy of one session/week) might havecontributed to the acceptability of the RCT. Likewise, a pilotstudy by Steven Roose and colleagues94 succeeded in ran-domizing ten patients to psychoanalysis or CBT. Another on-going German study by Marianne Leuzinger-Bohleber andManfred Beutel95 includes an RCT in which patients are ran-domized to psychoanalysis (two or three times weekly) orCBT. Although the results of these latter two studies arenot yet available, the RCTs discussed here demonstrate thatrandomization is not impossible; we recommend that furtherRCTs be conducted in this field.

In the meantime, psychoanalysis has to rely mainly onpre/post cohort studies, and it is often argued that suchstudies might overestimate the ES of a treatment. Thisdrawback of the cohort study design and the related possi-bility of biased outcomes96,97 cannot be denied, but severalextended reviews demonstrate that, in practice, no system-atic differences have been found in the results of RCTs ver-sus those of cohort studies and pre/post studies.14,98–102

In a meta-analysis comparing nonrandomized effectivenessstudies with randomized efficacy studies of anxiety disor-ders, Stewart and Chambless103 found a very small differ-ence (Cohen’s d = �0.08 [significant]) between the ESs ofthe two types of studies. In addition, other studies showthat patients receiving no treatment improve minimally.Norton and Price104 found an ES of 0.25 for placebogroups in studies of anxiety disorders, and Leichsenringand Rabung (unpublished data) an ES of 0.12 in controlgroups of psychoanalytic therapies.

Knowledge of the “natural, untreated” course of the per-sonality pathology of this target group would be helpful ininterpreting the results of pre/post studies. For obvious rea-sons, such knowledge is scarce. Most people that suffer doseek, and fortunately often find, help. Some research sug-gests that the symptoms of personality disorders somewhatlessen over time, but this research is based almost exclu-sively on individuals who have been exposed to treat-ment105–108 or young children or adolescents, in whompersonality change is more expected.105,109 Several longi-tudinal studies, however, have investigated natural changesin personality of adults. Franz and colleagues110 investi-gated the spontaneous, long-term course of neurotic spec-trum disorders, personality disorders, stress reactions, andsomatoform disorders in a representative sample of the nor-mal adult population of Mannheim over a period of 11 years.They found a high correlation between the first and lastmeasurements 11 years later (r = .55) and strong evidencefor a long-term course of psychological impairment. Robertsand DelVecchio111 meta-analyzed 152 longitudinal studies(including 55,000 individuals) and compiled 3,217 test/retestcorrelations. They found that personality traits were in-creasingly stable in adulthood (r = 0.31 in childhood; r = 0.64at 30 years of age; r = 0.74 between 50 and 70 yearsof age). Terracciano and colleagues112 presented a longitudi-nal study measuring intra-individual personality change of

684 subjects who were tested at regular intervals of first 6and then 12 years. Individual stability on ten scales of per-sonality dimensions was high (r = 0.75), and the stability in-creased slightly when people were over 30 years of age. Thisresearch indicates that personality traits and pathologyseem, when untreated, fairly stable in adult populations.More research in this area is necessary, and it could serveas a control for otherwise uncontrolled studies of longduration.

Finally, it seems that more and more researchers valueuncontrolled effectiveness studies that parallel controlledones. As Stewart and Chambless103 concluded in their re-cent meta-analysis of CBT, “One of the most contentiousissues in evidence-based practice is the extent to whichresults from randomized controlled trials can be general-ized to routine clinical practice. Uncontrolled effectivenessresearch permits the researcher to maximize external va-lidity by testing treatments (with prior supporting efficacyresearch) in all types of naturalistic circumstances to evalu-ate whether these treatments translate well to the clinicalsetting.”

In the present meta-analysis, the number of studies issmall; the studies are of varying quality; and they each con-tain small samples of patients. The results therefore rest ona relatively narrow foundation. The treatment and patientgroups also vary considerably, and outcomes are not differ-entiated by DSM disorder. A further limitation of moststudies reviewed is that they report only on completers anddo not perform intent-to-treat analyses. Completers analy-sis may exaggerate results. There were only five studies thatused follow-up periods, and their lengths were short (witha maximum of 3.5 years). These brief follow-up periodsmay be important, as our results suggest that the effectsafter a longer follow-up period are smaller than after ashorter one.

Finally, many psychoanalysts believe that the conceptof scientific research (with its measurements, randomiza-tion, and strict criteria and procedures) is alien to psycho-analysis. Many would argue that the criteria used in suchresearch—such as the frequency of sessions, the use of a couch,or the presence of particular diagnoses—fail to capture,or even correlate with, the core elements of psychoanalysis.They would see the researcher as an unwanted “thirdparty.” And they would argue that the process of psycho-analysis and the changes in patients cannot be reliablycaught in simple, oversimplifying measurement instruments.In this context, it is worth noting that the measurements ofpersonality change in this meta-analysis were mostly doneby self-report scales such as the Inventory of InterpersonalProblems, Sense of Coherence Scale, and Social AdjustmentScale. We believe that these outcomes should be subjectedto more psychoanalytically relevant personality measure-ments or factors such as the Adult Attachment Interview,the Minnesota Multiphasic Personality Inventory, projectivetests, quality of object relations, and defense styles.



ConclusionsWe found evidence that psychoanalysis yields substantialpre/post and pre/follow-up change in patients presentingwith complex mental disorders for whom this type of treat-ment is indicated. These results are almost exclusivelybased on a small number of pre/post cohort studies, which,from the perspective of evidence-based medicine, are ofonly moderate scientific strength, as they lack control groups.Therefore, we cannot draw firm conclusions regarding theeffectiveness of psychoanalysis. Controlled studies are ur-gently needed that (1) describe patient samples in bothDSM and psychoanalytic diagnostic terms, (2) describethe treatment in more detail, (3) use intention-to-treat anal-yses, (4) apply in-depth, psychoanalytic personality out-come measures, (5) use long-term follow-up, (6) monitordropout, (7) ensure treatment integrity, and (8) includecost-effectiveness measures.

Declaration of interest: The authors report no conflicts ofinterest. The authors alone are responsible for the contentand writing of the article.

REFERENCES1. Shedler J. The efficacy of psychodynamic psychotherapy.

Am Psychol 2010;65:98–109.2. Leichsenring F, Rabung S. Long-term psychodynamic psych-

otherapy in complex mental disorders: update of a meta-analysis. Br J Psychiatry 2011;199:15–22.

3. Bachrach H, Galatzer-Levy R, Skolnikoff A, Waldron S.On the efficacy of psychoanalysis. J Am Psychoanal Assoc1991;39:871–916.

4. Galatzer-Levy R, Bachrach H, Skolnikoff A, Waldon S. Doespsychoanalysis work? New Haven, CT: Yale University Press,2000.

5. Doidge N. Empirical evidence for the efficacy of psychoan-alytic psychotherapies and psychoanalysis: an overview. Psy-choanal Inq 1997;suppl:102–50.

6. Fonagy P. An open door review of outcome studies in psyc-hoanalysis. London: International Psychoanalytical Associa-tion, 2002.

7. Doidge N. Is psychoanalysis effective? Econ Neurosci 2001;3:41–7.

8. de Maat S, de Jonghe F, Schoevers R, Dekker J. The effective-ness of long-term psychoanalytic therapy: a systematic re-view of empirical studies. Harv Rev Psychiatry 2009;17:1–23.

9. Jacobs DH. Three models of training. Am Psychoanalyst2007;41:11–9.

10. Mertens W. Einfuhrung in die psychoanalytische therapie[Introduction to psychoanalytic therapy], vol. 2. Stuttgart:Kohlhammer, 1990.

11. Gabbard GO. Long-term psychodynamic psychotherapy: abasic text. Arlington, VA: American Psychiatric Publishing, 2004.

12. Kernberg OF. A severe sexual inhibition in the course of thepsychoanalytic treatment of a patient with a narcissisticpersonality disorder. Int J Psychoanal 1999;80:899–908.

13. Fonagy P, Moran GS. Understanding psychic change in childpsychoanalysis. Int J Psychoanal 1991;72:15–22.

14. Leichsenring F, Rabung S. Effectiveness of long-term psycho-dynamic psychotherapy: a meta-analysis. JAMA 2008;300:1551–65.

15. American Psychiatric Association. Diagnostic and statisticalmanual of mental disorders. 4th ed. Washington, DC:APA, 1994.

16. Sandell R, Blomberg J, Lazar A, Carlsson J, Broberg J,Schubert J. Varieties of long-term outcome in psychoanalysisand long-term psychotherapy: a review of findings in theStockholm Outcome of Psychoanalysis and PsychotherapyProject (STOPP). Int J Psychoanal 2000;81:921–42.

17. Doidge N, Simon B, Brauer L, Grant DC, et al. Psychoan-alytic patients in the U.S., Canada, and Australia: I. DSM-III-R disorders, indications, previous treatment, medications,and length of treatment. J Am Psychoanal Assoc 2002;50:575–614.

18. Doidge WJ, et al. Psychoanalytic patients in the U.S., Canada,and Australia: II. A DSM-III-R validation study. J AmPsychoanal Assoc 2002;50:615–27.

19. Caligor E, Stern BL, Hamilton M, et al. Why we recommendanalytic treatment for some patients and not for others.J Am Psychoanal Assoc 2009;57:677–94.

20. de Jonghe F, de Maat S, Barber JP, et al. Designs for studyingeffectiveness of long-term psychoanalytic treatments: bala-ncing level of evidence and acceptability for patients. J AmPsychoanal Assoc 2012;60:361–87.

21. Cuijpers P, van Straten A, Warmerdam L, Andersson G. Psy-chological treatment of depression: a meta-analytic databaseof randomized studies. BMC Psychiatry 2008;8:36.

22. Alderson P, Green S, Higgins JPT, eds. Cochrane reviewers’handbook: 4.2.2. Chichester, UK: John Wiley & Sons.http://www.mv.helsinki.fi/home/hemila/karlowski/handbook_4_2_2_Karlowski.pdf

23. Leichsenring F. Randomised controlled versus naturalisticstudies: a new research agenda. Bull Menninger Clin 2004;68:137–51.

24. Cohen J. Statistical power analysis for behavioural sciences.Hillsdale, NJ: Lawrence Erlbaum, 1988.

25. Comprehensive meta-analysis (version 2.2.021). Englewood,NJ: Biostat.

26. Hedges LV, Vevea JL. Fixed- and random-effects models inmeta-analysis. Psychol Methods 1998;3:486–504.

27. DunlapWP, Cortina JM, Vaslow JB, BurkeMJ.Meta-analysisof experiments with matched groups or repeated measuresdesigns. Psychol Methods 1996;1:170–7.

28. Hedges LV, Olkin I. Statistical methods for meta-analysis.New York: Academic, 1985.

29. Huedo-Medina TB, Sanchez-Meca J, Botella J, Marin-Martinez F. Assessing heterogeneity in meta-analysis: Q sta-tistic or I2 index. Psychol Methods 2006;11:193–206.

30. Higgins JP, Thompsom SG, Deeks JJ, Altman DG. Measur-ing inconsistency in meta-analyses. BMJ 2003;327:557–60.

31. Duval S, Tweedie R. Trim and fill: a simple funnel-plot basedmethod of testing and adjusting for publication bias in meta-analysis. Biometrics 2000;56:455–63.

32. Berghout CC, Zevalkink J. Klinisch geval of worried well?Een beschrijving van patienten voorafgaand aan psycho-analytische behandeling. Psychologie en Gezondheid 2007;35:76–84.

33. Berghout CC, Zevalkink J. Differential selectivity of patientsassigned to long-term psychoanalytic treatment. J Am PsychoanalAssoc 2007;55:294–9.

34. Berghout CC, Zevalkink J. Identifying clinical cases amongpatients assigned to psychoanalytic treatment. BullMenningerClin 2008;72:163–78.

35. Berghout CC, Zevalkink J, de Jong JTVM. Symptomenen persoonlijkheidsproblemen voor, tijdens en na langdurigepsychoanalytische behandelingen: een multiple-cohort studie.Psychologie en Gezondheid 2010;38;66–75.

S. de Maat et al.


http://www.mv.helsinki.fi/home/hemila/karlowski/handbook_4_2_2_Karlowski.pdf

http://www.mv.helsinki.fi/home/hemila/karlowski/handbook_4_2_2_Karlowski.pdf

36. Berghout CC, Zevalkink J, de Wolf MHM. Psychoanlayseen psychoanalytische psychotherapie: Nederlands onderzoeknaar de effectiviteit van beide behandelvormen. Tijdschriftvoor Psychotherapy 2010;36:22–39.

37. Berghout CC, Zevalkink J. Clinical significance of long-termpsychoanalytic treatment. Bull Menninger Clin 2009;73:7–33.

38. Berghout CC, Zevalkink J, de Jong JTVM. 2010. Effective-ness of long-term psychoanalytic treatment: measuring person-ality functioning and symptomatic distress in a multiple-cohortdesign. PhD diss., VU University, Amsterdam, Netherlands. http://dare.ubvu.vu.nl/bitstream/handle/1871/15871/dissertation.pdf;jsessionid=0B3A8164AB35F765B1B956665FD9C413?sequence=1

39. Berghout CC, Zevalkink J, Hakkaart-van Roijen L. A cost-utility analysis of psychoanalysis versus psychoanalytic psy-chotherapy. Int J Technol Assess Health Care 2010;26:3–10.

40. Berghout CC, Zevalkink J, Hakkaart-van Roijen L. The ef-fects of long-term psychoanalytic treatment on health care uti-lization and work productivity and their associated costs. JPsychiatr Pract 2010;16:209–16.

41. Berghout CC, Zevalkink J, Katzko MW, de Jong JTVM.Changes in symptoms and interpersonal problems during thefirst two years of long-term psychoanalytic psychotherapy andpsychoanalysis. Psychol Psychother 2012;85:203–19.

42. Berghout CC, Zevalkink J, de Wolf MHM. Psychoanalyseen psychoanalytische psychotherapie: effect groottes enklinische significantie. Tijdschrift voor Psychotherapie 2010;36:22–39.

43. Zevalkink J, Berghout CC. Expanding the evidence base forthe cost-effectiveness of long-term psychoanalytic treat-ment. J Am Psychoanal Assoc 2006;54:1313–9.

44. Zevalkink J, Berghout CC. Door de bank genomen. Hoeeffectief zijn psychoanalytische behandelingen? Amsterdam:Nederlands Psychoanalytisch Instituut, 2008.

45. Zevalkink J, Berghout CC. Klinische besluitvorming tenaanzien van indicatie voor psychoanalyse en psychoanalytischepsychotherapie: een empirische invalshoek. Tijdschrift voorPsychotherapie 2008;34:151–68.

46. Zevalkink J, Berghout CC. Mental health characteristics ofpatients assigned to long-term ambulatory psychoanalytictreatment: psychoanalysis versus psychoanalytic psycho-therapy. Psychother Res 2008;18:316–25.

47. Cogan R, Porcerelli JH. Clinician reports of personalitypathology of patients beginning and patients ending psycho-analysis. Psychol Psychother 2005;78:235–48.

48. Erle JB, Goldberg DA. The course of 253 analyses from se-lection to outcome. J Am Psychoanal Assoc 2003;51:257–93.

49. Grande T, Dilg R, Jakobsen T, et al. Differential effects of twoforms of psychoanalytic therapy: results of the Heidelberg-Berlin study. Psychother Res 2006;16:470–85.

50. Rudolf G, Dilg R, Grande T, Jakobsen T, et al. Effektivitatund Effizienz psychoanalytischer Langzeittherapie: die Praxis-studie Analytische Langzeitpsychotherapie [Effectiveness andefficiency of long-term psychoanalytic psychotherapy: the prac-tice study of long-term psychoanalytic psychotherapy]. In:Gerlach A, Springer A, Schlosser A, eds. Psychoanalyse desGlaubens [Psychoanalysis of religious belief]. Giessen:Psychosozial-Verlag, 2004.

51. Huber D, Klug G. Munich Psychotherapy Study (MPS): theeffectiveness of psychoanalytic longterm psychotherapy fordepression. In: Society for Psychotherapy Research, ed. Bookof abstracts: from research to practice. Ulm, Germany: UlmerTextbank, 2006:154.

52. Huber D, Henrich G, Gastner J, Klug G.Must all have prices?The Munich Psychotherapy Study. In: Levy RA, Ablon JS,Kachele H, eds. Current clinical psychiatry: psychodynamic

psychotherapy research: evidence-based practice and practice-based evidence. New York: Humana, 2012.

53. Kantrowitz J, Singer J, Knapp PH. Methodology for aprospective study of suitability for psychoanalyis: the roleof psychological tests. Psychoanal Q 1975;44:371–91.

54. Kantrowitz J, Paolitto F, Sashin J, Solomon L, Katz A. Affectavailability, tolerance, complexity and modulation in psycho-analysis: a follow-up of a longitudinal, prospective study. JAm Psychoanal Assoc 1986;34:529–59.

55. Kantrowitz J. Suitability for psychoanalysis. In: Langs R, ed.The yearbook of psychoanalysis and psychotherapy, vol. 2.New York: Guilford, 1987:403–15.

56. Kantrowitz J, Katz A, Paolitto F, Sashin J, Solomon L.Changes in the level and quality of object relations in psy-choanalysis: follow-up of a longitudinal prospective study. JAm Psychoanal Assoc 1987;35:529–60.

57. Kantrowitz J, Katz A, Paolitto F, Sashin J, Solomon L. The roleof reality testing in psychoanalysis: follow-up of 22 cases. JAm Psychoanal Assoc 1987;35:367–86.

58. Kantrowitz J, Katz AL, Paolitto F. Follow-up of psychoanal-ysis five to ten years after termination: 1. Stability of change.J Am Psychoanal Assoc 1990;38:471–96.

59. Kantrowitz J, Katz AL, Paolitto F. Follow-up of psychoanal-ysis five to ten years after termination: 2. Development ofthe self-analytic function. J Am Psychoanal Assoc 1990;38:637–54.

60. Knekt P, Lindfors O, Laaksonen MA, et al. Helsinki Psy-chotherapy Study Group. Quasi-experimental study on theeffectiveness of psychoanalysis, long-term and short-termpsychotherapy on psychiatric symptoms, work ability andfunctional capacity during a 5-year follow-up. J Affect Disord2011;132:37–47.

61. Leichsenring F, Biskup J, Kreische R, Staats H. The Gottingenstudy of psychoanalytic therapy: first results. Int J Psychoanal2005;86:433–55.

62. Loffler-Stastka H, Rossler-Schulein H, Skale E. Pradiktorendes Therapieabruchs in psychoanalytische Behandlungenvon Patienten mit Personlichkeitsstohrungen. ZeitschriftPsychosomatischen und Medische Psychotherapie 2005;54:63–76.

63. Luborsky L, Stuart J, Friedman S, et al. The Penn Psy-choanalytic treatment collection: a set of complete andrecorded psychoanalyses as a research resource. J Am Psy-choanal Assoc 2001;49:217–34.

64. von Rad M, Senf W, Brautigam W. Psychotherapie undPsychoanalyse in der Krankenversorgung: Ergebnisse desHeidelberger Katamnese-Projektes. Psychother PsychosomMed Psychol 1998;48:88–100.

65. Heuft G, Seibuchler-Engec H, TaschkeM, SenfW. Langzeit-outcome ambulanter psychoanalytischer Psychotherapien undPsychoanalysen. Ein textinhaltsanalytische Untersuchung von53 Katamneseinterviews. Forum der Psychoanalyse Zeitschrift1996;12:42–355.

66. Kordy H, von Rad M, Senf W. Time and its relevance forsuccessful psychotherapy. Psychother Psychosom 1988;49:212–22.

67. Rudolf G, Manz R, Ori C. Ergebnisse psychoanalytischerTherapien. Z Psychosom Med Psychoanal 1994;40:25–40.

68. Wallerstein R. Forty-two lives in treatment: a study of psy-choanalysis and psychotherapy. New York: Guilford, 1986.

69. KernbergO, Burstein ED,Coyne L, AppelbaumA,Horwitz L,Voth H. Psychotherapy and psychoanalysis: the final report ofthe Menninger Foundation’s Psychotherapy Research Project.Bull Menninger Clin 1972;36:1–275.

70. HartyM,Horwitz L. Therapeutic outcome as rated by patients,therapists, and judges. Arch Gen Psychiatry 1976;33:957–61.



http://dare.ubvu.vu.nl/bitstream/handle/1871/15871/dissertation.pdf;jsessionid=0B3A8164AB35F765B1B956665FD9C413?sequence=1




71. Sashin JI, Eldred S, van Amerongen ST. A search for predictivefactors in institute supervised cases: a retrospective study of183 cases from 1959–1966 at the Boston PsychoanalyticalSociety and Institute. Int J Psychoanal 1975;56:343–59.

72. Weber JJ, Bachrach HM, Solomon M. Factors associatedwith outcome of psychoanalysis: a report of the ColumbiaPsychoanalytic Center Research Project (II). Int Rev Psy-choanal 1985;12:127–41.

73. Bachrach HM, Weber JJ, Solomon M. Factors associated withthe outcome of psychoanalysis (clinical and methodologicalconsiderations): report of the Columbia Psychoanalytic CenterResearch Project (IV). Int Rev Psychoanal 1985;12:379–89.

74. Duhrssen A. Dynamische Psychotherapie, Psychoanalyse undanalytische Gruppenpsychotherapie im Vergleich. Z Psy-chosom Med Psychoanal 1986;32:161–80.

75. Grossarth-Maticek R, Eysenck HJ. Prophylatic effect ofpsychoanalysis on cancer prone and heart disease proneprobands as compared with control groups and behaviourtherapy groups. J Behav Ther Exp Psychiatry 1990;21:91–9.

76. Keller W, Westhoff G, Dilg R, Rohner R, Studt HH; StudyGroup on Empirical Psychotherapy Research in AnalyticalPsychology. Efficacy and cost effectiveness aspects of outpatient(Jungian) psychoanalysis and psychotherapy—a catamnesticstudy. Berlin: Department of Psychosomatics and Psychotherapy,University Medical Center Benjamin Franklin, Free University ofBerlin, [1998]. http://www.uni-saarland.de/fak5/krause/ulm97/keller.htm

77. Leuzinger-Bohleber M, Target M, eds. Outcomes of psy-choanalytic treatment: perspectives for therapists and re-searchers. London, Philadelphia: Whurr, 2001.

78. Leuzinger-Bohleber M, Stuhr U, Ruger B, Beutel M. How tostudy the ‘quality of psychoanalytic treatments’ and their long-term effects on patients’ well-being: a representative, multi-perspective follow-up study. Int J Psychoanal 2003;84:263–90.

79. Hartmann S, Zepf S. Einflusse auf die Symptombesserungin der Psychotherapie bei Patienten mit unterschiedlichenBeschwerdebildern. Psychother Psychosom Med Psychol2004;54:445–56.

80. Stehle S. Psychotherapeutische Berfustatigkeit. Ergebnisseder DGPT-Therapeutenerhebung. In: Gerlach A, Schlosser A,Springer A, eds. Psychoanalyse des Glaubens [Psychoanalysisof religious belief]. Giessen: Psychosozial-Verlag, 2004.

81. Rascon SR, Corona PC, Lartugue T, Rios JM, Garza DL. Asuccessful trial utilizing the Leuzinger-Bohleber methodologyfor evaluation of psychoanalytic treatment: preliminary re-port. Int J Psychoanal 2005;86:1425–40.

82. Brockmann J, Schluter T, Eckert J. Langzeitwirkungenpsychoanalytische rund verhaltenstherapeutischer Langzeittherapien[Long-term outcome of long-term psychoanalytic and behav-ioral long-term therapy]. Psychotherapeut 2006;51:15–25.

83. Puschner B, Kraft S, Kachele H, Kordy H. Course ofimprovement over 2 years psychoanalytic and psychodynamicoutpatient psychotherapy. Psychol Psychother 2007;80:51–68.

84. Knekt P, Lindfors O, Valikoski M, LaaksonenM; the HelsinkiPsychotherapy StudyGroup.Quasi-experimental study on theeffectiveness of psychoanalysis, long-term and short-termpsychodynamic psychotherapy and solution focused therapyon psychiatric symptoms during a 5-year follow-up. Presenta-tion at the annual meeting of the Society for Psychotherapy Re-search, Madison, WI, June 2007.

85. Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C.Combined pharmacotherapy and psychological treatmentfor depression: a systematic review. Arch Gen Psychiatry2004;61:714–9.

86. Casacalenda N, Perry JC, Looper K. Remission in majordepressive disorder: a comparison of pharmacotherapy,

psychotherapy, and control conditions. Am J Psychiatry2002;159:1354–60.

87. Loffler-Stastka H & Steinmair D. Psychoanalytical theoryof affects and its applicability on the Affect Regulation andAffect Experience Q-Sort Test (AREQ). J Med Psychol2009;1(1):10–20. http://medicalpsychologyjournal.weebly.com/uploads/1/3/7/9/1379865/loffler_10.pdf

88. Newton-Howes G, Tyrer P, Johnson T. Personality disorderand the outcome of depression: a meta-analysis of publishedstudies. Br J Psychiatry 2006;188:13–20.

89. Leichsenring F, Leibing E. The effectiveness of psychodynamictherapy and cognitive behavior therapy in the treatment ofpersonality disorders: a meta-analysis. Am J Psychiatry 2003;160:1223–32.

90. Lambert MJ. Psychotherapy outcome research. In: BerginEA, ed. Handbook of psychotherapy. 3rd ed. New York:Wiley, 1986:94–129.

91. Smit Y, HuibersMJH, Ioannidis JPA, vanDyckR, van TilburgW, Arntz A. The effectiveness of long-term psychoanalyticpsychotherapy—a meta-analysis of randomized controlledtrials. Clin Psychol Rev 2012: 32:81–92.

92. Leichsenring F. Are psychodynamic and psychoanalytictherapies effective? A review of empirical data. Int J Psy-choanal 2005;86:841–68.

93. Seligman ME. The effectiveness of psychotherapy: the Con-sumer Reports Study. Am Psychol 1995;50:965–74.

94. Caligor E, Hilsenroth MJ, Devlin M, Rutherford BR, TerryM, Roose SP. Will patients accept randomization to psycho-analysis? A feasibility study. J Am Psychoanal Assoc 2012;60:337–60.

95. Leuzinger-Bohleber M, Beutel M. Psychoanalytic andcognitive-behavioral treatment: first data on the LARCdepression study. Presentation at the Psychoanalytic ProcessResearch Strategies conference, Ulm, Germany, June 2009.

96. Sacks H, Chalmers TC, Smith H Jr. Randomized versus his-torical controls for clinical trials. Am J Med 1982;72:233–40.

97. Kunz R, Oxman AD. The unpredictability paradox: reviewof empirical comparisons of randomised and non-randomisedclinical trials. Br Med J 1998;317:1185–90.

98. Concato J, Shah N, Horwitz RI. Randomised controlledtrials, observational studies and the hierarchy of researchdesigns. N Engl J Med 2000;342:1887–92.

99. Benson K, Hartz AJ. A comparison of observational studiesand randomized, controlled trials. N Engl J Med 2000;342:1878–86.

100. Shadish WR, Matt G, Navarro A, Phillips G. The effectsof psychological therapies under clinically representativeconditions: a meta-analysis. J Consult Clin Psychol 2000;126:512–29.

101. Driessen E, Cuijpers P, de Maat S, Abbass A, de Jonghe F,Dekker JJM. The efficacy of short-term psychodynamic psy-chotherapy for depression: a meta-analysis. Clin Psychol Rev2010;30:25–36.

102. Van HL, Dekker J, Koelen J. Patient preference comparedwith random allocation in short-term psychodynamic sup-portive psychotherapy with indicated addition of pharmaco-therapy for depression. Psychother Res 2009;19:205–12.

103. Stewart RE, Chambless DL. Cognitive behaviour therapyfor adult anxiety disorder in clinical practice: a meta-analysisof effectiveness studies. J Consult Clin Psychol 2009;77:595–606.

104. Norton PJ, Price EC. A meta-analytic review of adultcognitive-behavioral treatment outcome across the anxietydisorders. J Nerv Ment Dis 2007;195:521–31.

105. Lenzenweger MF, Desantis Castro D. Predicting changein borderline personality: using neurobehavioral systems

S. de Maat et al.


http://www.uni-saarland.de/fak5/krause/ulm97/keller.htm

http://www.uni-saarland.de/fak5/krause/ulm97/keller.htm

indicators within an individual growth curve framework.Dev Psychopathol 2005;17:1207–37.

106. Zanarini MC, Frankenburg FR, Henne J, Silk KR. Thelongitudinal course of borderline psychopathology. Am JPsychiatry 2003:160;274–83.

107. McGlashan TH, Grilo CM, Sanislow CA, et al. Two-yearprevalence and stability of individual DSM-IV criteria forschizotypical, borderline, avoidant and obsessive-compulsivepersonality disorders: toward a hybrid model of Axis II dis-orders. Am J Psychiatry 2005;162:883–9.

108. Stone M. Long-term outcome in personality disorders. Br JPsychiatry 1993;162:299–313.

109. de Clerq B, van Leeuwan K, van den NoortgateW, de Bolle M,de Fruyt F. Childhood personality pathology: dimensionalstability and change. Dev Psychopathol 2009;21:853–69.

110. Franz M, Lieberz K, Schmitz N, Schepank H. A decade ofspontaneous long-term course of psychogenic impairmentin a community population sample. Soc Psychiatry PsychiatrEpidemiol 1999;34:651–6.

111. Roberts BW, DelVecchio WF. The rank-order consistency ofpersonality traits from childhood to old age: a quantitativereview of longitudinal studies. Psychol Bull 2000;126:3–25.

112. Terraciano A, McCrae RR, Costa PT Jr. Intra-individual changein personality stability and age. J Res Pers 2010;44:31–7.

113. Derogatis LR, Lazarus L. SCL-90-R, Brief Symptom Inventory,and matching clinical rating scales. In: Maruish ME, ed. Theuse of psychological testing for treatment planning andoutcome assessment. New York: Hillsdale, 1974:217–48.

114. Beck AT, Ward CH, Mendelson MM, Mock J, Erbaugh J.An inventory for measuring depression. Arch Gen Psychiatry1961;4:561–71.

115. Spielberger CD, Gosuch RL, Lushene RE. Manual for theState-Trait Anxiety Inventory. Palo Alto, CA: ConsultingPsychologists, 1970.

116. Kiresuk TJ, Lund SH. Goal attainment scaling: research,evaluation and utilization. In: Schulberg HC, Baker F, eds.Program evaluation in health fields, vol. 2. New York:Human Science, 1979.

117. Rudolf G. Ein psychoanalytisch fundiertes Instrument zurPatient Selbstschatzung. Zeitschrift fur PsychosomatischenMedizin 1991;37:350–60.

118. Luborsky L. Clinician’s judgments of mental health. ArchGen Psychiatry 1962;7:407–17.

119. HamiltonM. A rating scale for depression. J Neurol NeurosurgPsychiatry 1960;23:56–62.

120. Hamilton M. The assessment of anxiety states by rating. B JMed Psychol 1959;32:50–5.

121. GuyW. ECDEU assessment manual for psychopharmacology.Rockville, MD: U.S. Department of Health, Education, andWelfare, Public Health Service, Alcohol, Drug Abuse, andMental Health Administration, National Institute of MentalHealth, Psychopharmacology Research Branch, Division ofExtramural Research Programs, 1976.

122. Horowitz LM, Strauss B, KordyH. Inventory of InterpersonalProblems. 2nd ed. Gottingen: Beltz, 2000.

123. Groth-Marnat G. Handbook of psychological assessment.Hoboken, NJ: Wiley, 1997.

124. Jacobsen NS, Follette WC, Revenstorf D. Psychotherapyoutcome research: methods for reporting variability andevaluating clinical significance. Behav Ther 1984;15:336–52.

125. Jacobsen NS, Roberts LJ, Berns SB, McGlinchey JB. Methodsof defining and determining the clinical significance of treatmenteffects. Description, application, and alternatives. J Consult ClinPsychol 1999;67:300–7.

126. Jacobsen NS, Truax P. Clinical significance: a statisticalapproach to defining meaningful change in psychotherapyresearch. J Consult Clin Psychol 1991;59:12–9.

127. DeWitt KN, Hartley DE, Rosenberg SE, Zilberg NJ,Wallerstein RS. Scales of Psychological Capacities: devel-opment of an assessment approach. Psychoanal ContempThought 1991;14:343–61.

128. Westen D, Shedler J. Revising and assessing Axis II, Part 1:developinga clinically andempirically valid assessmentmethod.Am J Psychiatry 1999;156:258–72.

129. Westen D, Shedler J. Revising and assessing Axis II, Part 2:toward an empirically based and clinically useful classificationof personality disorders. Am J Psychiatry 1999;156:273–85.

130. Antonovsky A. Unravelling themystery of health. San Francisco:Jossey-Bass, 1987.

131. Weissman M, Bothwell S. Assessment of social adjustmentby patient self-report. Arch Gen Psychiatry 1976;33:1111–5.

132. Ilmarinen J, Tuomi K, Klochars M. Changes in the workability of active employees over an 11-year period. Scand JWork Environ Health 1997;23(suppl 1):49–57.

133. Lehtinen V, Joukaama,M, Jyrkinen T, et al. Mental healthand mental disorders in the Finnish adult population [inFinnish, with English summary]. Turku/Helsinki: Publicationsof the Social Insurance Institution, 1991.

134. George C, Kaplan M, Main M. Adult Attachment Interview.Berkeley: University of California Press, 1996.



Appendix 1

Research Quality Score

Criteria Single or multiple cohort studyCohort study with matched

control groupa Randomized, controlled trial

Points Points Points

Study design

Randomization NA NA 35

Prospective design 10 10 NA

(Matched) control group NA 5, 10 NA

Patient group

Clear inclusion/exclusioncriteria

0, 1, 2 0, 1, 2 0, 1, 2

Characteristics described 0, 1, 2 0, 1, 2 0, 1, 2

Baseline scores comparable NA 0, 2, 4 0, 2, 4

Adequate sample size 0, 1, 2 0, 1, 2 0, 1, 2

Intervention

Clear description ofintervention

0, 2, 4 0, 2, 4 0, 2, 4

Therapist experience 0, 1, 2 0, 1, 2 0, 1, 2

Adherence therapist checked 0, 1, 2 0, 1, 2 0, 1, 2

Equal treatment groups NA 0, 2 0, 2

Outcome data

Outcome criteria clear andrelevant

0, 2, 4 0, 2, 4 0, 2, 4

Quality assessmentinstruments

0, 2, 4 0, 2, 4 0, 2, 4

Blind or independentassessment

0, 2, 4 0, 2, 4 0, 2, 4

Multiple assessors 0, 2, 4 0, 2, 4 0, 2, 4

Statistics

Adequate statistical methods 0, 1, 2 0, 1, 2 0, 1, 2

ITT or PP analyses 0, 2, 4 0, 2, 4 0, 2, 4

Confounders analyses 0, 1, 2 0, 1, 2 NA

Dropout

Dropout defined andacceptable

0, 2, 4 0, 2, 4 0, 2, 4

Dropout comparable NA 0, 1, 2 0, 1, 2

Maximum RQS 52 70 83

Cutoff score review 26 35 41


S. de Maat et al.


Appendix 1

Research Quality Score

Criteria Single or multiple cohort studyCohort study with matched

control groupa Randomized, controlled trial

Follow-up

Adequate length 0, 2, 4 0, 2, 4 0, 2, 4

Multiple assessors 0, 1, 2 0, 1, 2 0, 1, 2

Loss to follow-up defined andacceptable

0, 2, 4 NA NA

Loss to follow-up defined,acceptable, and comparable

NA 0, 2, 4 0, 2, 4

(Maximum score forfollow-up)

10 10 10

Maximum RQS 62 80 93

Appendix 2

Instruments Used in Studies

[1] SymptomsWith regard to measuring symptoms, the following instruments were used: Symptom Check List-90 (Derogatis & Lazarus[1994]),113 Beck Depression Inventory (Beck et al. [1961]),114 State-Trait Anxiety Inventory (Spielberger et al. [1970]),115 (mod-erated) Goal Attainment Scale (Kiresuk & Lund [1979]),116 Psychischer and sozial-kommunikativer Befund (Rudolf [1991]),117

Health Sickness Rating Scale (Luborsky [1962]),118 Hamilton Depression Rating Scale (Hamilton [1960]),119 Hamilton AnxietyRating Scale (Hamilton [1959]),120 Global Assessment of Functioning (DSM-IV), Positive Symptom Distress Index (based onthe SCL-90), Positive Symptom Total (based on the SCL-90), and Clinical Global Impression–Severity or –Improvement(Guy [1976]).121

[2] Personality and Social FunctioningWith regard to measuring changes in personality and psychosocial functioning, the following instruments were used: Inventory ofInterpersonal Problems (Horowitz et al. [2000]),122 Minnesota Multiphasic Personality Inventory (Groth-Marnat [1997])123 (usingthose clinical scales that were, at baseline, clinically elevated relative to a defined cutoff point [Jacobsen et al. (1984,1999),124,125 Jacobsen & Truax (1991)126], Scales of Psychological Capacities (DeWitt et al., [1991]),127 Shedler-Westen Assess-ment Procedure–200 (Westen & Shedler [1999]),128,129 Sense of Coherence Scale (Antonovsky [1987]),130 Social Adjustment Scale(Weissman & Bothwell [1976]),131 Work Ability Index (Ilmarinen et al. [1997]),132 work subscale of the Social Adjustment Scale(Weissman and Bothwell [1976]),131 and Perceived Psychological Functioning Scale (Lehtinen et al. [1991]).133 More in-depth mea-surements of personality change, such as the assessment of attachment styles, defense styles, or object relation-quality, were largelymissing or, as in the case of the Knekt study, not yet reported. One study (Berghout/Zevalkink et al. [2006–10, 2012])32–46 used theAdult Attachment Interview (George et al. [1996])134 for assessing outcomes.



Documents

AMA PRA Category 1 Credits™cme.lww.com/files/TheCurrentStateoftheEmpirical...INTRODUCTION As a therapeutic discipline, psychoanalysis encompasses both short- and long-term treatment