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Further reflections about the document Psychotherapy for Anxiety and Depression: benefits and costs

The document proposes a lot of useful information and suggests a very interesting perspective. However, it raises some methodological problems which cannot be circumvented. With Vittorio Lingiardi, we discussed this topic in the foreword to the Italian translation (2016) of a book by Levy, Ablon and Kächele (2012) on Psychodynamic psychotherapy research. I get from this text some concepts, supplemented with further reflections.


Introduction
The document proposes a lot of useful information and suggests a very interesting perspective. However, it raises some methodological problems which cannot be circumvented. With Vittorio Lingiardi, we discussed this topic in the foreword to the Italian translation (2016) of a book by Levy, Ablon and Kächele (2012) on Psychodynamic psychotherapy research. I get from this text some concepts, supplemented with further reflections.

What types of data in clinical decision making?
In a recent book (Magnavita, 2016) of collected papers on clinical decision making in mental health practice (and therefore also on the choice of effective psychotherapeutic treatments in front of different disorders) was repeatedly stated that the best psychological methods, models and services for helping clients are those that include the strongest available research evidence, delivered with clinical expertise and in line with patient values.
The Authors quoted a conspicuous amount of specific literature about this topic and, above all, the document on evidence-based practice in psychology by the APA Presidential Task Force (2006).
The concern to integrate the methodology of the Empirically Supported Treatments (EST) and the Randomized Control Trials (RCTs) with the expertise of clinically competent decision makers is not new in the debate on the effectiveness of psychological interventions. The best known example is the proposal to use also daily clinical practice as a natural laboratory (Westen, Novotny, & Thompson-Brenner, 2004). In other words, it is not a matter of contrasting EST vs non EST, but to quantify data from clinical practice in such a way as to derive scientifically valid generalizations across cases (p. 752). In this perspective, data from RCTs and clinical practice can be integrated into empirically informed treatments.
RCTs are obviously the method of choice when the treatment is directed to a circumscribed area of the psychopathological functioning, but if psychological intervention does not only address symptomatic relief or behavioral modification, RCTs are not the most appropriate methodological tool for a judgment of effectiveness. For this reason, it has long been considered the RCT methodology unsuitable for psychodynamic treatments, which aim to foster the development of psychological resources and abilities, involving the overall functioning of personality and not just its behavioral and symptomatic expressions.
Most recently, however, some psychodynamic oriented authors have attested the efficacy of psychoanalysis and psychodynamic psychotherapies for a wide range of psychopathological disorders, using the RCT methodology (Coleman Curtis, 2014;Fonagy, 2015;Leichsenring, 2008). In some cases the long-term effects of these treatments have been more durable than those of other types of therapy.
What provisional conclusions can we draw from these researches?

The plurality of approaches both in clinical practice and in research
The RCT methodology is also suitable for psychodynamic treatments if we want to evaluate their efficacy [ in promoting symptomatic improvements. Instead, as regards the propensity of psychoanalysis and psychodynamic treatments to produce personality transformation beyond symptomatic modification, RCTs remain an inadequate tool. As Roth and Parry (1997) wrote, RCTs must be considered no more than one part of the research cycle. Furthermore, we must not fall into the trap of the contrast between psychodynamic treatments and other types of psychosocial interventions, after having avoided the trap of EST vs. non-EST. The real point is to identify more accurately which types of treatments are indicated for what kinds of disorders. It is the link between specific therapeutic factors and key dysfunctions, which Fonagy (2006) suggests as the most important issue to be solved by current psychotherapy research.

Further reflections about the document Psychotherapy for Anxiety and Depression: benefits and costs
About two specific disorders (anxiety and depression), the literature on psychodynamic treatments yields meaningful results.
The effectiveness studies which have been conducted in naturalistic settings indicate that psychodynamic treatments for anxiety demonstrate large effects (Milrod, Busch, Leon et al., 2001;Crits-Christoph, Connolly, Azarian et al., 1996;Slavin-Mulford, Hilsenroth et al., 2011) . Patients in these studies treated with psychodynamic therapy evidenced considerable reduction in diagnosis, anxiety symptoms, depression, and global distress (i.e., large effects).
In addition, randomized control trials suggest that psychodynamic treatment for anxiety symptoms tends to be more efficacious than controls (Abbass, Hancock, Henderson, & Kisely, 2006). Moreover, the studies which have compared psychodynamic therapy to medication, suggest that psychodynamic therapy is as efficacious as pharmacological interventions (e.g. Ferrero, Piero, Fassina et al., 2007;Wiborg & Dahl, 1996).
Finally, the efficacy of psychodynamic therapy in relation to cognitive, behavioral, and CBT is more mixed, although there is a general trend for CBT to demonstrate small to moderate effects over psychodynamic treatments for anxiety disorders (e.g., Klein, Zitrin, Woerner, & Ross, 1983;Leichsenring, Salzer et al., 2009). Importantly, however, many of the studies comparing CBT to psychodynamic therapy found large effects for both treatments (e.g. Leichsenring, Salzer et al., 2009;Steinert, Munder et al., 2017).
The research data we just reported may be considered a good example of an empirically informed approach to treatment, to the extent that they do not contrast -but integrate -results from a naturalistic setting and RCTs data.

Future research directions
Reporting and commenting on these results in the already quoted book by Ablon, Levy and Kächele, Slavin-Mulford and Hilsenroth (2012, p. 134) write that much work remains and indicate some future research directions.
Given that anxiety disorders are frequently comorbid with one another (Andrews, Slade, & Issakidis, 2002) more studies examining the anxiety spectrum as a whole would help to represent the types of patients who actually present for treatment in clinical practice. The same concern should guide future studies on the treatment of depression.
It will be important for future research to examine the moderating effects of Axis I and Axis II comorbidity, as well as therapeutic alliance and aspects of technique.
We can remember that already Westen, Novotny and Thompson-Brenner (2004) addressed the researchers' attention to some important issues. Primarily, the need to identify the different types of patients requiring a psychological intervention: the same symptomatology may be the expression of different personality traits; patients can also be motivated in different ways to the psychotherapeutic intervention and have different expectations and ideas about it. The evaluation of topics such as alliance capacity and the choice of a suitable technique in relation to these clinical elements, are crucial to the good outcome of the treatment. In addition, the presence of other comorbid disorders, which alter the pattern of symptoms and affect the response to treatments.
Researches carried out according to the RCT methodology cannot ignore these topics. On the other hand, psychodynamic orientation research cannot pay attention only to improvements in personality functioning (often difficult to operationalize) and neglect the improvement of the symptoms for which the patient has called for help. The well-known psychoanalyst Owen Renik (2006) has specified that psychoanalysis should not be only an exercise of intellectual growth, but a real help relationship, that allows the patient to reduce his/her symptomatic suffering.
The concept of empirically supported treatments may integrate the contribution of RCTs in the evaluation of symptomatic improvement (efficacy) and data derived from daily clinical practice, attentive to the overall functioning of the subject (effectiveness). In this perspective, psychoanalysis and psychodynamic psychotherapies have been shown to be able to improve the symptoms, as well as to provide a meaningful contribution to the achievement of a more mature expression of resources and skills.
Point 13 of the document invite to promote investment in studies about the so called common factors such as therapeutic alliance, doctor-patient relationship, motivation toward treatment. Psychodynamic oriented research has long estimated the importance of these clinical elements. We believe that RCT methodology on the efficacy of psychological treatments can be integrated with the evaluation of these aspects. Without neglecting a topic that has been repeatedly discussed in many recent qualitative researches: the patient/customer satisfaction as an important element in evaluating outcomes and processes of a (not only psychotherapeutic) treatment. In other words, the patient's perspective about the care work (the patient values we mentioned earlier). But we'll talk about it another time.