Raymond A. Levy

Patient and Practitioner Influences on the Placebo Effect in Irritable Bowel Syndrome

Objective: To determine whether placebo responses can be explained by characteristics of the patient, the practitioner, or their interpersonal interaction. Methods: We performed an analysis of videotape and psychometric data from a clinical trial of patients with irritable bowel syndrome who were treated with placebo acupuncture in either a warm empathic interaction (Augmented, n = 96), a neutral interaction (Limited, n = 97), or a waitlist control (Waitlist, n = 96). We examined the relationships between the placebo response and a) patient personality and demographics; b) treating practitioner; and c) the patient-practitioner interaction as captured on videotape and rated by the Psychotherapy Process Q-Set. Results: Patient extraversion, agreeableness, openness to experience, and female gender were associated with placebo response, but these effects held only in the augmented group. Regression analyses controlling for all other independent variables suggest that only extraversion is an independent predictor of placebo response. There were significant differences between practitioners in outcomes; this effect was twice as large as the effect attributable to treatment group assignment. Videotape analysis indicated that the augmented group fostered a treatment relationship similar to a prototype of an ideal healthcare interaction. Conclusions: Personality and gender influenced the placebo response, but only in the warm, empathic, augmented group. This suggests that, to the degree a placebo effect is evoked by the patient-practitioner relationship, personality characteristics of the patient will be associated with the placebo response. In addition, practitioners differed markedly in effectiveness, despite standardized interactions. We propose that the quality of the patient-practitioner interaction accounts for the significant difference between the groups in placebo response. IBS = irritable bowel syndrome; FFI = Five Factor Inventory; PQS = Psychotherapy Process Q-Set; M-PQS = Modified Psychotherapy Process Q-Set.

Beyond brand names of psychotherapy: Identifying empirically supported change processes.

There is considerable debate about which empirical research methods best advance clinical outcomes in psychotherapy. The prevailing tendency has been to test treatment packages using randomized, controlled clinical trials. Recently, focus has shifted to considering how studying the process of change in naturalistic treatments can be a useful complement to controlled trials. Clinicians self-identifying as psychodynamic treated 17 panic disorder patients in naturalistic psychotherapy for an average of 21 sessions. Patients achieved statistically significant reductions in symptoms across all domains. Rates of remission and clinically significant change as well as effect sizes were commensurate with those of empirically supported therapies for panic disorder. Treatment gains were maintained at 6-month follow-up. Intensive analysis of the process of the treatments revealed that integrative elements characterized the treatments: Adherence to cognitive-behavioral process was most characteristic, adherence to interpersonal and psychodynamic process, however, was most predictive of positive outcome. Specific process predictors of outcome were identified using the Psychotherapy Process Q-Set. These findings demonstrate how process research can be used to empirically validate change processes in naturalistic treatments as opposed to treatment packages in controlled trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Psychodynamic Psychotherapy Research

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Neural Predictors of Successful Brief Psychodynamic Psychotherapy for Persistent Depression

Background: Psychodynamic psychotherapy has been used to treat depression for more than a century. However, not all patients respond equally well, and there are few reliable predictors of treatment outcome. Methods: We used resting 18F-fluorodeoxyglucose positron emission tomography (18FDG-PET) scans immediately before and after a structured, open trial of brief psychodynamic psychotherapy (n = 16) in conjunction with therapy process ratings and clinical outcome measures to identify neural correlates of treatment response. Results: Pretreatment glucose metabolism within the right posterior insula correlated with depression severity. Reductions in depression scores correlated with a pre- to posttreatment reduction in right insular metabolism, which in turn correlated with higher objective measures of patient insight obtained from videotaped therapy sessions. Pretreatment metabolism in the right precuneus was significantly higher in patients who completed treatment and correlated with psychological mindedness. Conclusions: Resting brain metabolism predicted both clinical course and relevant psychotherapeutic process during short-term psychodynamic psychotherapy for depression.

A Session of Psychoanalysis as Analyzed by the Psychotherapy Process Q-Set: Amalia X, Session 152

Freud initiated the study of speciman reports of psychoanalytic work with the so-called Irma-dream [1]. This material has been re-analyzed a number of times (for example [2]). In the same vein, the Dora-case [3] has retained a prestigious pivotal position in availing itself to continuous re-elaboration and re-interpretation [4]. However, few detailed examples are available to extended scrutiny where “primary data” [5] are at hand. We leave utilized primary verbation data in our process analysis of a session of the psychoanalysis at process.

The Role of the Couch in Psychoanalysis: Proposed Research Designs and Some Preliminary Data

Ever since Freud, the couch has been viewed as an important—some would argue essential—component of psychoanalysis. Although many theoretical papers and case reports have addressed the use of the couch in psychoanalysis, no empirical study has investigated its effect on psychoanalytic process or outcome. After a review of the literature, a number of research designs are proposed that might be used in such an investigation. Finally, preliminary empirical data are presented from archived audiotapes of two psychoanalyses: one in which the patient switched from lying down to sitting up, and one in which the opposite occurred. The aim is to stimulate research-oriented psychoanalysts to undertake empirical investigations of the theoretical concepts underlying use of the couch and, more generally, to present a specific example of research as a paradigm for a broader research agenda for empirical investigation of the key theoretical ideas underlying psychoanalysis.

The Development of a Psychoanalytic Outcome Study Choices, Conflicts, and Consensus

This article tells the story of the development of an outcome study of psychoanalysis and describes the debate that took place over critical methodological issues. The protocol committee included career psychotherapy researchers who have conducted rigorous outcome studies, clinical psychoanalysts, study methodologists, and a statistician with clinical trial expertise. The committee worked for two years to develop the study design. This project is based on the premise that clinical psychoanalysis is a treatment. Areas specifically addressed are the goals and hypothesis of the study, inclusion and exclusion criteria, choice of psychotherapies as comparison treatments, definition of treatments and selection of therapists, use of medication, development of a treatment adherence measure, randomization of patient assignment vs. patient self-selection, and primary outcome measures. The execution of this outcome study will require significant effort and resources. A positive result would boost the standing of psychoanalysis, but the results may not support the primary hypothesis that there are therapeutic benefits unique to psychoanalysis and that psychoanalysis can effect demonstrable changes in a patient’s mental life and adaptation that are not achieved by treatments of different orientation and/or lesser intensity. However, more important than whatever specific results emerge is what executing such a study requires of our field: the process of addressing the clinical issues that a study design requires, the creation of a network of analysts around the country working on a common project, and the joining of the clinical psychoanalytic community with a community of psychodynamic researchers.

A Naturalistic Treatment for Panic Disorder

Although cognitive-behavior therapy (CBT) has repeatedly demonstrated treatment efficacy for panic disorder [1], establishing the empirical basis for psychodynamic psychotherapy (PD) remains important because CBT is not effective for all panic patients [2, 3]. Busch [4] argues persuasively that diversifying the number of empirically supported psychotherapeutic options available to panic patients is necessary to fully respond to the range of panic patients‘ clinical needs. As Busch et al. note, while highly effective for many individuals, CBT does not work for all panic patients [2, 3].

An Empirical Comparison of Short-Term Psychodynamic Psychotherapy Processes: Distinctive Process Factors Between Successful and Unsuccessful Therapeutic Outcome Groups.

There has been increasing demand on psychodynamicially oriented therapists to empirically demonstrate the effectiveness of their interventions, and to associate these interventions with successful therapeutic outcome. Studies focused on psychoanalytic process have identified several process-related variables influencing the nature of the treatment and have demonstrated how therapy process changed over time, along with associations between process variables and outcome (Ablon, Levy, and SmithHansen 2011). The good nature of the interaction of the therapeutic dyad, 602878 APAXXX10.1177/0003065115602878Poster SummariesPoster Summaries research-article2015

Bridging Technology and Psychotherapy: Toward Investigating Psychological and Neural Correlates of Psychodynamic Psychotherapy

Generations of therapists can attest to the ability of psychotherapy to effect change in people’s lives, changes that we now know undoubtedly reflect changes in the brain. At the same time, as Gabbard [1] suggests, the need to understand explicitly the neural basis of psychotherapy through scientific research is greater than ever. In this chapter, we review an ongoing study investigating psychological and neural correlates of brief psychodynamic psychotherapy in individuals suffering from major depression. The study, to the best of our knowledge, is the first of its kind; most studies to date of neural correlates of psychotherapy have focused on cognitive behavioral therapy and interpersonal therapy (IPT) ([2], Chap. 9).