At treatment termination an average of 77% of the patients achieved scores under a clinically defined cutoff score or criterion (indicating they were falling in the range of a nonclinical population) of a symptom or general instrument, 48% more than the number of patients scoring under those cutoff scores at baseline. At follow-up an average of 75% achieved that status. For personality and psychosocial functioning instruments, the results indicate that an average of 62% of the patients achieved scores under a clinically defined cutoff score or criterion (indicating that they fell in the range of a nonclinical population), 34% more than the number of patients scoring under those cutoff scores at baseline. At follow-up, an average of 65% achieved such a status.
Based on the absence of significant differences between the adjusted mean ESs (and 95% CI) and the observed values for any of the main comparisons, we failed to find 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 mean ES for publication bias of all studies based on only symptom instruments was lower at post-treatment after adjusting for publication bias (Cohen’s d = 1.36; 95% CI, 1.03–1.65). The number of trimmed studies was two, indicating that (based on the funnel plot that shows the spreading of studies and their ESs) due to publication bias, two studies in the field of psychoanalysis might be missing. This publication bias refers to the possibility of studies not being published (perhaps due to study quality or minor results). However, the adjusted value represents a small difference from the 1.52 that we found in this meta-analysis.
We found that psychoanalysis yields substantial pre/post and pre/follow-up change for patients presenting with long-standing, complex mental disorders—most often a combination of DSM-IV mood or anxiety disorders and personality disorders. At treatment termination, the mean pre/post ES was 1.27 for all outcome instruments taken together, 1.52 for symptom instruments, and 1.08 for personality and social functioning outcomes, all indicating substantial pre/post change. At follow-up the mean pre/follow-up ESs 1.46, 1.65, 1.31, respectively, indicating a stable effect. The majority of patients (62%–76%) achieved a clinically significant change, and these figures seemed stable at follow-up. Posttest means showed that after their treatment, psychoanalysis patients mostly fall in the range of nonclinical groups.
As our findings are based on pre/post studies, the effects of psychoanalysis cannot be compared to the effects of possible alternative treatments; consequently, firm conclusions about effectiveness are not possible here.
The dropout rate (between 3% and 33%) did not seem higher in psychoanalysis than in short-term psychotherapies (e.g., 47% in Pampallona et al.85 and 37%–54% in Casacalenda et al.),86 which is notable in view of the length of treatment. Two of the three studies with the highest dropout rates involved more severe pathology, with 100% of the patients presenting with a personality disorder.62,64–66,87
Overall, the heterogeneity in the analyses was moderate, indicating that there are probably systematic differences between the outcomes. The heterogeneity might be influenced by the different measurement instruments used and by differences in patient populations and the treatments used. For instance, 72% of the patients in the Berghout and Zevalkink study32–46 met criteria for personality disorders, and these patients showed lower ESs on depression instruments. By contrast, 34% of the patients in the Huber and Klug study51,52 and 19.50% in the Knekt60 study had personality disorders, and both groups of patients showed higher ESs on depression instruments. Although we can reach no definitive conclusions regarding the relationship between personality disorders and depression outcomes, Newton-Howes and colleagues88 have shown in a meta-analysis that the presence of personality disorders reduces the effect of treatment outcomes for depression.
It could also be suggested, however, that heterogeneity was mainly influenced by the differences between the studies with lower session frequency—all performed in Germany—and those with higher session frequency. The German studies were characterized by better study quality, lower prevalence of patients with personality disorders, and, on average, fewer sessions and higher ESs. In Germany, insurance coverage for psychoanalysis is limited to 300 sessions. How this influences treatment results or indications remains unclear. More research is needed to shed further light on our findings; for example, dose-response studies would be especially useful.
Sub-analyses at treatment termination indicate that some heterogeneity 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 the study used different measurement instruments; whereas the Rudolf study used only one (German) questionnaire (Psychischer und sozial-kommunikativer Befund), whereas the other studies used various, more internationally employed instruments such as the Beck Depression Inventory, Hamilton Depression Rating Scale, Inventory of Interpersonal Problems, and Symptom Checklist–90. In addition, the Rudolf study, dating from 1994, is the oldest of the German studies. Advances in the discipline could potentially have contributed to the differences seen in the more recent studies. That said, the differences remain, without further investigation, largely unexplained.
For personality measurements at treatment termination, heterogeneity was almost zero, indicating that heterogeneity resulted from differences in the effects of symptom change across studies. At follow-up, heterogeneity was also very low to zero in the statistically significant sub-analyses.
Publication bias seems fairly low in our study. ESs computed after the trim-and-fill method did not differ significantly from the mean ESs found in the meta-analysis. Due to the small number of studies, however, calculations of publication bias must be interpreted cautiously.
Nine of the 14 studies encompassed a long-term psychoanalytic psychotherapy condition in addition to psychoanalysis. In this article we restricted ourselves to the pre/post findings of psychoanalysis studies. The question of whether the results of psychoanalysis and LTPP in nonrandomized studies can be compared is a complicated one. One study51,52 did randomize patients to psychoanalysis or LTPP. The authors found that at follow-up, psychoanalysis performed better than LTPP on personality measures (Inventory of Interpersonal Problems and Scale of Psychological Capacities) and on a goal attainment scale.
Finally, we found that in this meta-analysis, therapist ratings were the lowest, that observer ratings were the highest, and that patient ratings fell in between (a possibly counterintuitive result in that one might expect therapists to rate their own work higher than independent observers). There are pros and cons, of course, for utilizing the ratings provided by these three different groups. On the one hand, independent observers have less vested interest in the treatment and might therefore be less biased in judging results. On the other hand, patients and therapists have much more exposure to the actual evidence than independent observers. The literature is not in agreement on the question of whether patients and therapists might overestimate therapy success. In analyzing the findings of the Menninger Foundation’s psychotherapy research project, Harty and Horwitz70 found that both therapists (65%) and patients (54%) rated therapy success higher than independent judges (38%). Other studies have found, though, that self-reports present more modest results than observer ratings.76,78,89,90
Several limitations of our meta-analysis caution against overinterpreting the results. The most important limitation is the use of pretest/posttest analyses; all studies, except for one, were pre/post cohort studies, lacking (randomized) control groups. In evidence-based medicine’s hierarchy of evidence, RCTs present strong scientific evidence, whereas the evidence from pre/post cohort studies is only moderate. The importance of control groups is made clear by Smit and colleagues91 in their recent meta-analysis of LTPP. Their subgroup analysis of the domain’s “target problems showed that LTPP did significantly better when compared to control treatments without a specialized psychotherapy component, but not when compared to various specialized psychotherapy control treatments.” Considered from this point of view, the evidence for the effects of psychoanalysis cannot be more than of moderate strength.
Several researchers have pointed to the difficulties and limitations of RCTs in the field of intensive, long-term treatments, of which psychoanalysis is paradigmatic.64,92,93 de Jonghe and colleagues20 brought attention to the limited feasibility of RCTs because of the restricted acceptability of the control conditions—especially, but not exclusively, in psychoanalysis. They argue that randomization to the most informative control conditions (waiting list, placebo, and no treatment), coupled with the extended length of the treatment period, renders RCTs unacceptable for patients. Most patients considering a psychoanalytic treatment have previously tried therapies with a much lower frequency or duration with no success, and no evidence-based therapies with frequency of sessions and duration comparable to psychoanalysis are available yet to serve as additional conditions in an RCT. Patients are not likely to accept the risk of being allocated by chance to a control condition that they know all too well.
In the meantime, psychoanalysis has to rely mainly on pre/post cohort studies, and it is often argued that such studies might overestimate the ES of a treatment. This drawback of the cohort study design and the related possibility of biased outcomes96,97 cannot be denied, but several extended reviews demonstrate that, in practice, no systematic differences have been found in the results of RCTs versus those of cohort studies and pre/post studies.14,98–102 In a meta-analysis comparing nonrandomized effectiveness studies with randomized efficacy studies of anxiety disorders, Stewart and Chambless103 found a very small difference (Cohen’s d = −0.08 [significant]) between the ESs of the two types of studies. In addition, other studies show that patients receiving no treatment improve minimally. Norton and Price104 found an ES of 0.25 for placebo groups in studies of anxiety disorders, and Leichsenring and Rabung (unpublished data) an ES of 0.12 in control groups of psychoanalytic therapies.
Knowledge of the “natural, untreated” course of the personality pathology of this target group would be helpful in interpreting the results of pre/post studies. For obvious reasons, such knowledge is scarce. Most people that suffer do seek, and fortunately often find, help. Some research suggests that the symptoms of personality disorders somewhat lessen over time, but this research is based almost exclusively on individuals who have been exposed to treatment105–108 or young children or adolescents, in whom personality change is more expected.105,109 Several longitudinal studies, however, have investigated natural changes in personality of adults. Franz and colleagues110 investigated the spontaneous, long-term course of neurotic spectrum disorders, personality disorders, stress reactions, and somatoform disorders in a representative sample of the normaladult population of Mannheim over a period of 11 years. They found a high correlation between the first and last measurements11 years later (r = .55) and strong evidence for a long-term course of psychological impairment. Roberts and DelVecchio111 meta-analyzed 152 longitudinal studies (including 55,000 individuals) and compiled 3,217 test/retest correlations. They found that personality traits were increasingly stable in adulthood (r = 0.31 in childhood; r = 0.64 at 30 years of age; r = 0.74 between 50 and 70 years of age). Terracciano and colleagues112 presented a longitudinal study measuring intra-individual personality change of 684 subjects who were tested at regular intervals of first 6 and then 12 years. Individual stability on ten scales of personality dimensions was high (r = 0.75), and the stability increased slightly when people were over 30 years of age. This research indicates that personality traits and pathology seem, when untreated, fairly stable in adult populations. More research in this area is necessary, and it could serve as a control for otherwise uncontrolled studies of long duration.
Finally, it seems that more and more researchers value uncontrolled effectiveness studies that parallel controlled ones. As Stewart and Chambless103 concluded in their recent meta-analysis of CBT, “One of the most contentious issues in evidence-based practice is the extent to which results from randomized controlled trials can be generalized to routine clinical practice. Uncontrolled effectiveness research permits the researcher to maximize external validity by testing treatments (with prior supporting efficacy research) in all types of naturalistic circumstances to evaluate whether these treatments translate well to the clinical setting.”
In the present meta-analysis, the number of studies is small; the studies are of varying quality; and they each contain small samples of patients. The results therefore rest on a relatively narrow foundation. The treatment and patient groups also vary considerably, and outcomes are not differentiated by DSM disorder. A further limitation of most studies reviewed is that they report only on completers and do not perform intent-to-treat analyses. Completers analysis may exaggerate results. There were only five studies that used follow-up periods, and their lengths were short (with a maximum of 3.5 years). These brief follow-up periods may be important, as our results suggest that the effects after a longer follow-up period are smaller than after a shorter one.
Finally, many psychoanalysts believe that the concept of scientific research (with its measurements, randomization, and strict criteria and procedures) is alien to psychoanalysis. Many would argue that the criteria used in such research—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 “third party.” And they would argue that the process of psychoanalysis and the changes in patients cannot be reliably caught in simple, oversimplifying measurement instruments. In this context, it is worth noting that the measurements of personality change in this meta-analysis were mostly done by self-report scales such as the Inventory of Interpersonal Problems, Sense of Coherence Scale, and Social Adjustment Scale. We believe that these outcomes should be subjected to more psychoanalytically relevant personality measurements or factors such as the Adult Attachment Interview, the Minnesota Multiphasic Personality Inventory, projective tests, quality of object relations, and defense styles.
We found evidence that psychoanalysis yields substantial pre/post and pre/follow-up change in patients presenting with complex mental disorders for whom this type of treatment is indicated. These results are almost exclusively based on a small number of pre/post cohort studies, which, from the perspective of evidence-based medicine, are of only moderate scientific strength, as they lack control groups. Therefore, we cannot draw firm conclusions regarding the effectiveness of psychoanalysis. Controlled studies are urgently needed that (1) describe patient samples in both DSM and psychoanalytic diagnostic terms, (2) describe the treatment in more detail, (3) use intention-to-treat analyses, (4) apply in-depth, psychoanalytic personality outcome measures, (5) use long-term follow-up, (6) monitor dropout, (7) ensure treatment integrity, and (8) include cost-effectiveness measures.
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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Appendix 1 Research Quality Score
Appendix 2 Instruments Used in Studies
With regard to measuring symptoms, the following instruments were used: Symptom Check List-90 (Derogatis & Lazarus ),113 Beck Depression Inventory (Beck et al. ),114 State-Trait Anxiety Inventory (Spielberger et al. ),115 (moderated) Goal Attainment Scale (Kiresuk & Lund ),116 Psychischer and sozial-kommunikativer Befund (Rudolf ),117 Health Sickness Rating Scale (Luborsky ),118 Hamilton Depression Rating Scale (Hamilton ),119 Hamilton Anxiety Rating Scale (Hamilton ),120 Global Assessment of Functioning (DSM-IV), Positive Symptom Distress Index (based on the SCL-90), Positive Symptom Total (based on the SCL-90), and Clinical Global Impression–Severity or –Improvement (Guy ).121
 Personality and Social Functioning
With regard to measuring changes in personality and psychosocial functioning, the following instruments were used: Inventory of Interpersonal Problems (Horowitz et al. ),122 Minnesota Multiphasic Personality Inventory (Groth-Marnat )123 (using those 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., ),127 Shedler–Westen Assessment Procedure–200 (Westen & Shedler ),128,129 Sense of Coherence Scale (Antonovsky ),130 Social Adjustment Scale (Weissman & Bothwell ),131 Work Ability Index (Ilmarinen et al. ),132 work subscale of the Social Adjustment Scale (Weissman and Bothwell ),131 and Perceived Psychological Functioning Scale (Lehtinen et al. ).133 More in-depth measurements of personality change, such as the assessment of attachment styles, defense styles, or object relation-quality, were largely missing or, as in the case of the Knekt study, not yet reported. One study (Berghout/Zevalkink et al. [2006–10, 2012])32–46 used the Adult Attachment Interview (George et al. )134 for assessing outcomes.