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Treating Patients Who Strain the Research Psychotherapy Paradigm

Markowitz, John C. MD*†; Kaplowitz, Matthew PhD; Suh, Eun-Jung PhD*†; Meehan, Kevin B. PhD; Neria, Yuval PhD*†; Jonker, Hanske BSc; Rafaeli, Alexandra PsyD*; Lovell, Karina PhD

The Journal of Nervous and Mental Disease: July 2012 - Volume 200 - Issue 7 - p 594–597
doi: 10.1097/NMD.0b013e31825bfaf4
Original Articles

Clinical trials of psychotherapy require diagnostic homogeneity, which implies a convergence of clinical presentations. Yet research study patients present diversely, and patients who do not fit a treatment paradigm may greatly complicate delivery of the study psychotherapy. The research literature has not addressed this issue. The authors use case illustrations of three psychotherapies – Prolonged Exposure, Relaxation Therapy, and Interpersonal Psychotherapy – from an ongoing psychotherapy outcome trial of posttraumatic stress disorder to describe psychotherapeutic responses to complex, “atypical” patients who strain standard treatment paradigms. Therapists required flexibility, and occasionally deviations from strict protocol, in treating heterodox patients. Such heterogeneity of presentation may have implications for psychotherapy outcome in research trials. Despite lack of discussion in the literature, many trials may face such issues.

*Department of Psychiatry, Columbia University; †New York State Psychiatric Institute; ‡Department of Psychology, Long Island University; §University of Utrecht, Netherlands; and ∥University of Manchester, United Kingdom.

Supported in part by grant MH 079078 from the National Institute of Mental Health (Markowitz, PI), and by the New York State Psychiatric Institute. #NCT00739765.

Conflicts of Interest: None. Drs. Markowitz and Neria currently receive grant support from the National Institute of Mental Health and salary support from the New York State Psychiatric Institute. Dr. Neria also receives support from Columbia University. Dr. Markowitz also receives minor book royalties from American Psychiatric Press, Basic Books, and Oxford University Press, and an editorial stipend from Elsevier Press. Dr. Neria receives royalties from Cambridge University Press.

Send reprint requests to John C. Markowitz, MD, New York State Psychiatric Institute, New York, NY United States. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.