Suffering, glory and outcomes in psychotherapy.

Hoffman, Lowell W.

Psychologist practitioners are trained to understand human mental and emotional suffering through the lens of a manualized nosology (DSM) of symptom clusters. They are taught that reduction of these symptoms by means of the most efficient techniques that are empirically supported by a randomized controlled trial (RCT) methodology is the treatment of choice and the ethical practice of psychotherapy.

To the chagrin of the psychologist practitioner who adheres to the empirically validated tail of psychotherapy research which wags the dog of most prescribed clinical practice, short-term positive psychotherapeutic outcomes all too often devolve into the patient's relapse and symptom substitution. Such importunate clinical outcomes present the practitioner with several considerations including: a) the treatment plan is incomplete, b) the patient needs medication, c) the patient is non-compliant with the treatment, d) another practitioner may be a better "fit" for the patient, e) the practitioner is better suited for teaching, writing, research, consultation, mediation, coaching and/or managing care for a third party payor, or f) the practitioner's therapeutic model is inappropriate for intervening with the vicissitudes of the patient's world.

The conscientious practitioner is usually imbued with sufficient humility to first privilege the hypothesis that his or her treatment plan is incomplete. However, a poignant moment of reckoning eventually comes for the practitioner when there is nothing left in the toolbox to add to the treatment plan. This is a trying event for the practitioner who can tacitly if not actively relinquish some or all of the therapeutic alliance with the patient. Such ruptures in the therapeutic alliance are also trying for the patient and can be a source of new suffering for him or her. Henry, Schacht and Strupp (1986,1990) have identified the following practitioner behaviors in poor-outcome cases: hostile control (i.e., belittling and blaming), hostile separation (i.e., ignoring and neglecting), complexity (i.e., messages simultaneously conveying contradictory information), and less affiliative autonomy granting (i.e., affirming and understanding)(see also Castonguay, Boswell, et al. 2010). This present article is especially written for the practitioner who has experienced the desire to "go deeper" with a patient, who perhaps has felt a sense of failing a patient, and who is looking for alternative models.

An Integrative Theological Excursus on Suffering

The psychologist practitioner who is engaged in Christian integration is committed to a consilience between complementary Judeo-Christian principles, truths, meanings and ways of relating with empirically validated psychotherapeutic interventions. Not only practitioners working integratively with patients, but also the contemporary church and the churches of previous centuries have languished in theological occlusion with the problem of suffering and evil. Pessimistic eschatologies, elaborate theodicies, and mystical suffering myths have been propounded by the church to ameliorate the stain of incalculable sufferings upon the good news of the death and resurrection of Jesus the Christ and a Christian theology of hope. The church's unsatisfying attempts to respond to a world and a church that continues to suffer have failed, at least in part, because of a theological lacuna to the centrality of suffering on the way to realizing a new heaven and new earth.

A theological preoccupation with the power of Christ's resurrection and the implications of this power for the believer has left the church without an adequate register for the proper alignment of suffering in the already extant and progressively coming kingdom of God. Karl Barth (1956) observed that only the early church prior to Constantine demonstrated a pathos capable of being a church in weakness with the accompanying competence through grace to suffer, and to suffer with the other who suffers. From Barth, one can understand that the church since Constantine has perpetuated a defensive reaction formation against suffering by ensuring through countless ignominious compromises, rationalizations and atrocities that it remains a church in power. A prophetic Barth looked forward to a time when a post-Constantinian church could be a church in weakness, a church that "... set its hope wholly and utterly on grace" (1956, p. 338).

Philippians 3

A deconstruction of triumphalistic readings of Paul yields a theology of suffering that is robust and satisfying. In fact, Paul propounds that there is only a cursory knowledge of Christ without individual suffering for the believer in Jesus. He intimates a comprehensive knowing of Christ in "the power of his resurrection, and the fellowship of sharing in his sufferings [emphasis added], becoming like him in his death, and so, somehow, to attain to the resurrection from the dead" (Phil. 3:10-11, New International Version). Innumerable misreadings of this text eclipse the plain meaning of Paul's affirmation regarding suffering. First, there is a fellowship of sharing in Jesus' sufferings. Our comprehension of this experience of sharing in Jesus' sufferings in the present and coming kingdom of God is barely possible without Moltmann's (1993) contribution on the suffering God. The Son who lost His Father for us, and the Father who lost His only begotten Son for us, is the same God who empathically weeps now for His children who are suffering presently on earth. The drying of the last tear in the New Jerusalem is surely the tear of God (Rev. 21:4). Jesus weeps for our losses as surely as he wept for Mary and Martha's loss of Lazarus which was also his own loss (John 11: 35).

Second, there is no intimate knowing of Jesus without being in his suffering with him. Jesus taught us to pray to the Father for deliverance from evil, but not from suffering. To ask for a bye on suffering with Jesus is as disingenuous as crafting a wedding vow that commits to being with the other in health only, but not in sickness. The Christian who desires to know Christ only in the power of his resurrection exalts in Christ's "finished work" and is at risk for personally pursuing the church's greatest error--to be and to perpetuate being the church in power.

Third, the Christian must reckon that entering into this intimacy of suffering with Christ definitively includes becoming like him in his death. While this death of self surely implies a dying to the lusts of flesh and eye and to the pride of life, and sometimes martyrdom, it means much more. The theologian Hegel (1824, 1987) and the psychoanalyst Winnicott (1969) help us to understand this death as a laying down of ourselves for the other who suffers and the survival of the other's destructive attitudes and behaviors for the other's well-being. Marie Hoffman thoroughly and convincingly explicates this understanding in Toward Mutual Recognition: Relational Psychoanalysis and the Christian Narrative (in press). A condensed compilation of her thought is found in her articles in this journal (Hoffman, 2010a, 2010b).

Fourth, there is little mystery in this suffering with Christ. The kingdom is here and as ministers of reconciliation (2 Cor. 5:18), we are here to be the face of the one mediator between God and humans (1 Tim. 2:5), e.g. we are here to love God and love our neighbor (Matt. 22:37-39) which somehow will attain for the many the resurrection from the dead. There is mystery here, but the mystery is not as much in humans knowing a fellowship of suffering with Christ, as it is in the "somehow" that eventuates in the realization of a new heaven and new earth. The mystery that is in the human suffering since Calvary for this author, is in all of the anguish that God went through when Jesus became like us and gave up His very self for us, and then left us with still quite a lot of suffering to go through.

A possible understanding of human suffering since Calvary is that the coming of the kingdom of God (shalom) is a shared project between the God who discerns good from evil and chooses the good, and the joint heirs in Christ (Rom. 8:17) who can now also discern good from evil and choose the good. Human knowledge of good and evil could not be reversed to an original human innocence (Gen. 2:17, 3:3ff); therefore God in Christ and through the Holy Spirit has empowered regenerated ministers of reconciliation who can now live in the ambivalence of good and evil and choose the good and overcome the evil with the good (Rom. 12:21).

In this fellowship, or partnership with God, those who love God and surrender to His project of shalom, live in the eternal present to do the greater works than those done when Jesus was here with us (John 14:12). Jesus did not once for all in our time and space existence put an end to suffering and death, which we inherited through our collective choice to know good and evil; rather Jesus, in concert with the work of the Spirit and all who live and work as ministers of reconciliation, will in a second fullness of time, put an end to suffering and death in the new heaven and new earth. Establishment of the kingdom of God is the shared work of the Son of God and the Spirit of God in concert with the people of God who experience the call of His purpose (Rom. 8:28) in a grand activity of co-creativity, a building of a fellowship of oneness in which all flesh will become one as God is One (John 17:22).

Romans 8

Less thorough readings of Paul's magnum opus trudge through the "darkness" of the first seven chapters of depravity and debauchery, faith and faithlessness, struggle and death, which according to these readings, reaches a crescendo, "What a wretched man I am! Who will rescue me ...?" (Rom. 7:24). And then ... a thousand points of light break through the darkness, "Therefore, there is no condemnation for those who are in Christ Jesus...." (Rom. 8:1). These readings of Romans 8 focus on the glad tidings of no condemnation, and like an express train that skips certain stations, rush to the end of the chapter to the "life verse" of countless Christians, particularly those with a pessimistic eschatology: "And we know that in all things God works for the good of those who love him...." (Rom. 8:28).

The missed local stop between Rom. 8:17 and 8:27 affirms that "... we are ... co-heirs with Christ, if indeed we share in his sufferings [emphasis added], in order that we may also share in his glory [emphasis added]" (Rom. 8:17). Such readings overlook much in this section.

The whole creation that has groaned with suffering right up until the time of Christ and Paul (Rom. 8:22), will continue to groan and every person will continue to groan, in spite of "the first fruits of the Spirit", until the time of the "redemption of our bodies" (Rom. 8:23), the time when we will all have faces, the time when we will all be one as the Father and Son are One, at the commencement of the glory of the fully realized kingdom of God in the new heaven and new earth. Until then, "the Spirit helps us in our weakness," i.e., our suffering (Rom. 8:26).

In the prevalent readings of Romans 8, the apprehension of the obvious meaning of the Christian's suffering in this passage is as densely defended against as the narcissist's apperception of shame. These prevailing readings tend to obfuscate the meaning of suffering in a manner that reminds one of the husband who cleans the entire house with the hope that his wife will experience in this service his love, only to hear his wife exclaim, "Thank you, but all I needed was a hug!" The preponderance of suffering for most Christians is not about being a martyr in a foreign land or bracing for an impending onslaught of a persecution closer to home. Present expectancies of the Christian's suffering tend to focus on persecution of Christians by the culture. This is happening; our culture has understandably been disillusioned and incensed by a church which has clung to and perpetuated its power. But the Christian's hyper-focus on dreaded suffering of grand-sized persecutions can also be understood (psychoanalytically-speaking), as a defense against acknowledging Jesus' invitation to every follower to surrender to myriad everyday sufferings, many of which bring Christians face-to-face with aspects of themselves and the other that cause great discomfort when acknowledged.

Most Christian suffering is mundane when contrasted to persecution. The epicenter of most suffering is more often than not intrapsychic. This suffering includes personal grieving over an unloving response to or action against or marginalization of a loved one, the sacrifice involved in providing for the orphan, widow, indigent and ill or visitation of a prisoner. This suffering requires weeping with those who weep, resisting the urge to dismiss the other's suffering with a platitude, or worse yet, with the judgment of Job's friends. Sometimes this suffering is a recognition of one's finiteness, that loving one's spouse precludes being there for another. Suffering is a calling to love one's enemies until there are no more enemies, and when having done all, to eventually yield to the loss of one's loved ones, sustenance, standing, health and life. More than anything else, Christian suffering is about knowing Christ.

The Christian's suffering wrestles with the foreknowledge of what is coming and pleads, "Father, if it is possible, let this cup pass...." (Matt. 26:39). The Christian's suffering sobs for the other as it groans, "How often I would have gathered you to myself . , but you would not" (Matt.23:37). The Christian's suffering of aloneness and the perceived distance of God screams out, "My God, why have you forsaken me?" (Matt. 27:46). This same suffering echoes the prophet's forlorn anger and disillusionment, "How much longer Lord ...?" (Jer. 4:21; 12:4). The opening of Mother Theresa's diaries, so filled with uncertainty and doubt, did not uncloak another Christian hoax; rather they revealed a woman who intimately knew Christ in the fellowship of His sufferings before Calvary, at Calvary, and since Calvary. This is the way of the kingdom, this is the way to the kingdom, this is how the kingdom will come. When we pray, "Our Father . ," we pray for this kingdom and far from asking for the bye from suffering, we ask, " Your will be done ... in me, I want to know you--intimately--in the power of your resurrection, and in the fellowship of your sufferings, so that somehow, I along with the many, will experience your glory."

Back to Psychotherapy Outcomes

For those who have endured to the end the preceding theological excursus, what does a Christian theology of suffering have to do with psychotherapy outcomes? For the practitioner committed to Judeo-Christian integration, a theology of suffering has everything to do with outcomes. A theology of suffering helps us to understand that our role of serving as ministers of reconciliation, of staying in the suffering as we somehow endure until there is resurrection, often means that sitting with the other "among the ashes" for a week of days (i.e., short-term solution focus) is not sufficient (Job 2). A theology of suffering calls us to persevere with the other in the ashes with the distress of sometimes not knowing what to do or say.

This theology constrains us to discontinue standardized interventions with a person when they are not working, to be willing to tolerate the distress of not always having an empirically validated process to follow (although this should not be relied on as a rationalization for sloppy or unethical treatment). This theology constrains us to potentially gut-wrenching personal realizations that we must experience our own personal psychotherapy to avert further suffering by our patients due to our other-than-secure attachment styles, internalized hostilities, excessive need to be liked or admired, inability to receive criticism and/or difficulty tolerating negative emotion (see Castonguay, et al., 2010, p.45).

To be a practitioner willing to suffer with the other will surely call us to follow a therapeutic trajectory of sometimes, if not often, becoming sin for the other, bearing reproach for another, becoming soiled with the other. This theology of suffering contravenes any primary concerns regarding how we will feel when a colleague inquires, "Are you still treating her?" or what we will say when the "care" manager asks, "Why is this person still in treatment?" This theology of suffering calls us to give up on a treatment plan when it is not working, and above all, to avoid the placing of any blame on the patient.

Psychoanalytic Psychotherapy as an Alternative Model for Practitioners

One anecdotal tale (reference unknown) remembers Sigmund Freud stating that psychoanalysis should be the treatment of last resort, i.e. if something less onerous helps, by all means choose the less burdensome option. While this article is especially written for colleagues who are searching for alternatives to what they now practice, the intent of the article is not to supplant what is categorically helpful. For example, specific anxiety conditions such as panic disorder and simple phobia respond well to short-term, manualized (non-psychodynamic) treatments and are empirically supported as having lasting effects (Westen et al., 2004).

Current research demonstrates that the benefits of psychodynamic psychotherapy for numerous other Axis I and Axis II disorders not only are efficacious, but endure and increase with time. (See below). Reasons abound among colleagues who are hesitant or opposed to investigating the benefits of psychoanalytic psychotherapy. The interested reader is directed to Shedler (2006) for a discussion of this phenomenon. Perhaps the most obvious reason that practitioners do not consider the benefits of psychodynamic psychotherapy, is that they have been taught that arcane aspects of psychoanalysis are still the superstructure of the treatment. The reality is, facets of psychoanalysis needed to die and have died.

Facets of Psychoanalysis Needed to Die

Psychoanalysis came to psychology through an incredible human being who insisted on honesty. Whatever else psychoanalysis was, it was certainly Sigmund Freud's prophetic rebuke of a power-obsessed, pseudo-Christian empire which condoned the persecution of some of it's people (particularly Jews). Freud's (unconscious?) secular recapitulation of a historic Judeo-Christian sensibility of a desperately wicked heart that cannot be known through his "discovery" of the unconscious, heralded his sweeping rejection of the falsehood he experienced among the populace of the fading Hapsburg dynasty. (1) His early topographical model of the human psyche as conscious, preconscious, and unconscious and his exploration of the oppositional life forces of eros and thanatos held much promise for his secular, religious-empire-rejecting understanding of humanity and religion. On his way to a Darwinian-inspired scientific model of the human organism, Freud replaced his tri-partite topographical model of conscious, preconscious and unconscious with a tri-partite structural model of id, ego, and superego which in the German rendering were "it, I and over-T (Bettelheim, 1982).

Freud's structural model of id, ego and superego can be understood as a psychic hydraulic system of three inter-related drive-containing chambers with valves that can be manipulated to maintain a quiescence in the human psyche through sustaining an equilibrium between opposing forces within the chambers. Too much pressure in one chamber could be compensated for by a ballast maneuver of equalizing the pressure between the three chambers.

In his attempt to craft a more scientific model of the human organism, Freud's shift toward the more positivist conceptions of his structural model of "it, I and over-I" eventually devolved in much post-war psychoanalytic theory and practice into a system of symptom reduction through reliance on the structural equilibrium theory. When alternative models of psychological theory and practice questioned the insufficiency of the structural model, many of the practitioners of the psychoanalytic project withdrew into gnostic-like societies of private knowledge that of course could not be understood by the "unenlightened."

Even more tragic were the instances of interminable psychoanalytic treatments where patients languished on the couches as living annuities for their aging analysts. Ghettos of practitioners of obsolete psychoanalytic theory and practice became sanctums of normal science (Kuhn, 1962) and these practices needed to die.

What Is Currently Practiced Psychoanalytic/ Psychodynamic Psychotherapy?

Shedler (2009) enumerates seven discrete features of current psychodynamic technique:

1. Focus on affect and expression of emotion

2. Exploration of attempts to avoid distressing thoughts and feelings

3. Identification of [painful or self-defeating] themes and patterns

4. Discussion of past experience (developmental focus)

5. Focus on interpersonal relations

6. Focus on the therapy relationship

7. Exploration of wishes and fantasies

In summarizing the overall focus of these seven features, Shedler states, "The goals of psychodynamic psychotherapy include, but extend beyond, symptom reduction. Successful treatment should not only relieve symptoms (i.e. get rid of something) but also foster the positive presence [within the patient] of psychological capacities and resources" (2009, p. 4, emphasis in original).

Current psychodynamic practices have been delineated in a study by Ablon & Jones (1998) in which recognized experts in psychoanalytic and cognitive behavioral therapies described "ideally" conducted treatments. Psychodynamic practices were found to include unstructured, open-ended dialogue that includes discussion of the patient's fantasies and dreams; identifying recurrent themes in the patient's experience; understanding patient's feelings/ perceptions in the light of past experiences; exploring feelings regarded by the patient as unacceptable (e.g., anger, envy, excitement); pointing out defensive operations; interpreting disowned or unconscious wishes, feelings and ideas; focusing on the therapy relationship and what is experienced in the dyad; and linking connections between the therapy relationship and other relationships.

By contrast, CBT practices were found to be structured by the therapist: introducing topics to the patient; functioning in a didactic role with the patient; offering direct guidance and advice to the patient; discussing the patient's treatment goals; offering explanatory information regarding the treatment and techniques; focusing on the patient's contemporaneous life situation; focusing on cognitive (rather than affective) themes, particularly thoughts and belief systems; and discussing and assigning homework for the patient to work on outside of the therapy session (Ablon & Jones, 1998).

Outcomes Research for Psychoanalytic Treatments

The present article is neither an outcomes studies paper nor a meta-analytic study, but rather a summary of other meta-analytic studies. The author is grateful to specific academicians and researchers who have written accessible articles on the current findings of psychodynamic outcomes research for the benefit of practitioners and their patients (see Shelder 2009; Westen, et. al., 2006; Wallerstein, 2006; Blatt, et.al., 2006; Dahlbender, et.al., 2006; Herzig & Licht, 2006; Leichsenring, 2006). It is important to acknowledge that some psychoanalysts previously resisted submitting psychodynamic treatments to the rigors of a randomized controlled trial methodology that would provide empirical support for this treatment. (2) Moreover, demonstration of psychoanalytic treatment efficacy has been limited by a "mismatch between what psychodynamic psychotherapy aims to accomplish and what outcome studies typically measure." (Shedler, 2009, p. 14). Consequently, the sheer number of studies of non-psychodynamic treatments dwarfs the available empirically rigorous studies of psychoanalytic treatments.

In certain halls of psychology, one can continue to hear professors, clinicians and researchers aver that there is little empirical evidence to support the continued practice of psychoanalytic treatments. This contention is no longer scientifically tenable in light of the current evidence. Shedler (2009) has done some heavy lifting in order to provide the interested scientist and practitioner with considerable empirical support for effect sizes of psychoanalytic psychotherapy which are comparable to the current "evidence-based treatments," and which also demonstrate some larger effect sizes for psychoanalytic treatments when they are compared with the manualized non-psychoanalytic treatments.

Shedler's Review of Empirical Evidence for Treatment Efficacy Findings

In order to establish a baseline for understanding effect size benefit in psychological and medical meta-analytic research, Shedler begins with examining effect sizes for anti-depressant medications. He notes that, "The overall mean effect size for anti-depressant medications approved by the FDA between 1987 and 2004 was .31 (Turner, et al., 2008)" (Shedler, 2009, p.5). Shedler further notes that according to Cohen (1988), in psychological and medical research, an effect size of .8 is understood to be large, an effect size of .5 is moderate, and an effect size of .2 is small. Effect size is a measurement expressed in standard deviation units which is used to contrast the difference between like variables measured in a treatment group and control groups.

What follows is a condensed summary of Shedler's (2009) review of the empirical evidence for the efficacy of psychodynamic treatments:

1. An "especially rigorous meta-analysis of psychodynamic psychotherapy" (Abbass, Hancock, et al., 2006) was conducted on 23 randomized controlled trials of 1,431 patients suffering from non-bipolar depressive disorders, anxiety disorders and somatoform disorders, often with co-morbidity of personality disorders. The patients received less than 40 hours of psychodynamic psychotherapy with controls ("treatment as usual," minimal treatment and wait list). An overall effect size of .97 for general symptom improvement increased to an effect size of 1.51 at follow up of 9 months or more, following end of treatment. Collateral effect sizes were as follows: for improvement of somatic symptoms, .81 with long-term follow-up effect size of 2.21; for improvement of anxiety, 1.08 with long-term follow-up effect size of 1.35; for depression, .59 with long-term effect size of .98. Shedler concludes, "The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended" (2009, p. 6).

2. A meta-analysis of 17 well-conceived randomized controlled trials of psychodynamic psychotherapies averaging 21 sessions found an effect size of 1.17 for psychodynamic psychotherapy compared to controls (Leichsenring, Rabung & Leibing, 2004). Pre-treatment to post-treatment effect size was 1.39 with an average 13 month follow-up effect size of 1.57. The authors clarified that psychodynamic psychotherapy left patients, "... better off with regard to their target problems than 92% of patients before therapy" (quoted in Shedler, 2009, p. 7).

3. A meta-analysis of 23 studies examining 1,870 patients in short-term psychodynamic psychotherapy for somatic conditions including dermatological, neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal and immunological complaints reported a .59 effect size improvement in somatic symptoms (Abbass, Kisely & Kroenke, 2009). Of the 23 studies that reported such data, there was a 77.8% reduction in healthcare utilization after completion of psychodynamic psychotherapy.

4. A meta-analysis studying the efficacy of psychodynamic psychotherapy (14 studies) and cognitive-behavioral therapy (11 studies) for treatment of personality disorders studied pre-treatment to post-treatment effect sizes with follow-up data of the longest term available (Leichsenring & Leibing, 2003). A mean length of treatment of 37 weeks with a follow-up of 1.5 years was reported for the psychodynamic psychotherapy. A mean length of treatment of 16 weeks with a mean follow-up of 13 weeks was reported for the cognitive-behavioral therapy. The pre-treatment to post-treatment effect sizes were as follows: psychodynamic psychotherapy, 1.46 / cognitive-behavioral therapy, 1.0.

5. A meta-analysis of the effects of long-term psychodynamic psychotherapies averaging 150 sessions for patients with mixed/moderate pathology and severe personality pathology was conducted by de Maat, de Jonghe, et al. (2009). Pre-treatment to post-treatment effect size for patients with mixed/moderate pathology was .78 for general improvement with an averaged 3.2 year post-treatment follow-up effect size of .94. Pre-treatment to post-treatment effect size for patients with severe personality pathology was .94 which increased to 1.02 at an average 5.2 years post-treatment follow-up.

Shedler (2009) states that what is "... especially noteworthy is the recurring finding that the benefits of psychodynamic psychotherapy not only endure, but increase with time" (p.8). He bases this conclusion on at least five independent meta-analyses (Abbass, et al., 2006; Anderson & Lambert, 1995; de Maat et al., 2009; Leichsenring et al., 2004; Leichsenring & Rabung, 2008). Shedler continues, "In contrast, the benefits of other (non-psychodynamic) empirically supported therapies tend to decay over time for the most common disorders (e.g., depression, generalized anxiety)" (2009, p. 8). He cites the following meta-analyses to substantiate his conclusions regarding the non-psychodynamic therapies: (Gloaguen, Cottraux, et al., 1998; Hollon, DeRubeis, Shelton, et al., 2005; Maat, Dekker, et al., 2006; Westen, Novotny & Thompson-Brenner, 2004).

Randomized controlled trials demonstrate marked improvements when psychodynamic psychotherapy is the chosen treatment for depression, anxiety, panic, somatoform disorders, eating disorders, substance abuse co-morbidity and personality disorders (Leichsenring, 2005; Milrod, et al., 2007). Of particular interest is the treatment of borderline personality disorder (BPD) with psychodynamic psychotherapy and findings of effect sizes that equaled or exceeded all other evidence-based treatments including dialectical behavior therapy, or DBT (Clarkin, et al., 2007). Moreover, intrapsychic changes including improved reflective functioning and attachment organization were found in patients who received psychodynamic psychotherapy, but not in patients treated with DBT (Levy, et al., 2006). Additionally, Bateman and Fonagy (2008) report at five year follow-up, patients receiving psychodynamic treatment for borderline personality disorder still met the criteria for BPD in only 13% of cases, while patients receiving other forms of treatment continued to meet the diagnostic criteria of BPD in 87% of the cases.

The Wildcard Factor in Non-Psychodynamic Treatments

Shedler (2009) also explores the consideration that, "The 'active ingredients' of therapy are not necessarily those presumed by the treatment or theory" (p. 10). He notes that, ". available evidence indicates that the mechanisms of change in cognitive therapy (CT) are not those presumed by the theory (p. 10, emphasis in original). Shedler quotes Kazdin who concluded in a review of empirically validated mechanisms of change in psychotherapy, "Perhaps we can state more confidently now than ever before that whatever may be the basis of changes with CT, it does not seem to be the cognitions as originally proposed" (Kazdin, 2007, p.8).

Shedler continues, "For these reasons, studies of therapy 'brand names' can be highly misleading. Studies that look beyond brand names by examining session videotapes or transcripts may be more informative (Goldfried & Wolfe, 1996; Kazdin, 2007, 2008)" (2009, p. 11). Ablon and Jones (1998) collected expert ratings of treatment interventions in psychodynamic and cognitive behavioral therapies that were considered free of eclectic influences. Researchers then rated therapists for their adherence to their stated treatment models. Therapist utilization of psycho-dynamically-oriented interventions like focus on the therapeutic alliance and the patient's stages of experiencing (see Castonguay et. al., 1996, p. 499), predicted efficacious outcomes for both "brand name" psychodynamic and cognitive therapies. Therapist utilization of CBT interventions like focusing on distorted cognitions believed to cause symptoms being treated, revealed little or no correlations with treatment outcomes for both "brand name" psychodynamic and cognitive therapies. An earlier study by Jones and Pulos (1993) reported similar findings (see also Horvath & Luborsky, 1993; Barber, Crits-Cristoph & Luborsky, 1996; Diener, Hilsenroth & Weinberger, 2007; Gaston et al., 1998; Hayes & Strauss, 1998; Hilsenroth et al., 2003; Hoglend et al., 2008; Norcross, 2002; Pos et al., 2003; Vocisano et al., 2004).

Potentially Harmful Treatments (PHTs)

Boisvert and Faust (2006) have demonstrated that practitioners tend to under-estimate the incidence of negative treatment outcomes. Across practice orientations, other studies reveal similar findings (Foa & Emmelkamp, 1983; Mays & Frank, 1985; Strupp, Hadley & Gomez-Schwartz, 1977; Strupp & Hadley, 1985). Lilienfeld (2007) has convincingly argued that a necessary but largely missing variable to be studied in the field of evidence-based outcomes research is the problem of potentially harmful treatments (PHTs) and has published a list of empirically based PHTs.

Castonguay et al. (2010) cite Schut et al. (2005) and Castonguay et al. (1996) to emphasize the potential harm both in psychodynamic and cognitive therapies when practitioners adhere to overutilization of interpretative technique or perseverating focus on cognitive causality of troubling emotions. Patient resistance and therapeutic alliance ruptures were found to be correlated with increased frequency of practitioner adherence to prescribed "brand name" interventions. Wampold (2006) offered evidence that psychotherapist effects may be more predictive of outcome than the therapeutic alliance. For instance, practitioners who were assessed with low self esteem and elevated levels of impulsiveness, worry and emotional expressiveness in relationships (i.e., anxious attachment styles) were found to be less empathic in the provision of psychotherapy. Henry, Strupp et al. (1993) found that practitioners who were hostile toward themselves were more likely to be hostile to patients.

Christianson (1991) and Hilliard, Henry, and Strupp (2000) have separately found that practitioner memories of parental negative perceptions during their child and adolescent development correlated with negative interpersonal psychotherapeutic process. Henry and Strupp (1994) found sufficient evidence to assert "a theoretically coherent link between early actions by parents toward the therapist, the therapist's adult introject state, vulnerability to counter-therapeutic process with their patients and differential outcome" [of a treatment] (p. 66). Freud (1937/1964) warned of the potential for practitioners to unconsciously perpetrate interventions with patients in order to experience reparation of their own hostility or guilt.

Psychoanalytic training emphasizes a personal training analysis that is integral to preparation for the ethical and effective practice of psychoanalytic psychotherapy. Training programs usually stipulate 200-400 hours of personal psychoanalytic psychotherapy so that the candidate will be better prepared to facilitate a therapeutic process less adulterated by the vicissitudes of his or her inner world. Practitioner consideration of attempting to provide psychoanalytic psychotherapy without the necessary prerequisite of experiencing a personal psychoanalytic psychotherapy is contraindicated in all cases.

Conclusion

The practitioner engaged in Judeo-Christian integration who is attuned to a theology of suffering, is mindful that his or her treatment can have harmful effects (e.g. potentially harmful treatments, PHTs) that may intensify and further ensconce the patient in suffering and avoids utilization of treatments that he or she is not trained to provide. Practitioner attunement to a theology of suffering will often guide practitioners to humbly recognize the necessity within themselves to do the work of their own personal psychotherapy. The way of the kingdom of God calls practitioners committed to integration to an experiential fellowship of sharing in the suffering of Jesus with each patient. The practitioner whose therapeutic sensibilities are guided by a theology of suffering and the research cited above, recognizes that the speediest path to a patient's symptom relief may not provide long-term benefit to the patient and may in fact, contribute to the patient's ongoing suffering and despair. "Cruel though it may sound, we must see to it that the patient's suffering, to a degree that it is somehow or other effective, does not come to an end prematurely" (Freud, 1910/1955, p. 162). Strong empirical support for the efficacy of psychoanalytic treatments endorse this worthy alternative to manualized non-psychoanalytic treatments, when indicated. The interested reader is encouraged to further dialogue with the present author and the other authors represented in this special issue concerning the potential benefits of contemporary psychoanalytic psychotherapy.

References

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Notes

(1) Peter Gay (1988) chronicles some of S. Freud's experiences with anti-semitism, "Infuriating and memorable enough to find a prominent place in his autobiography half a century later" (p. 27).

(2) Some notable psychoanalysts including Irwin Hoffman continue to articulate cogent arguments for the single case study as the only appropriate methodology for psychoanalytic research. Hoffman's impassioned objections to other research methodology was delivered as a plenary address at the American Psychoanalytic Assoc. Conference on Jan. 19, 2007 entitled, "Double thinking our way to 'scientific' legitimacy: The desiccation of human experience."

Lowell W. Hoffman

Brookhaven Center for Counseling & Development

Author

Lowell W. Hoffman (Ph.D., Clinical Psychology, Union Institute; Certificate, Post-Doctoral Program in Psychotherapy and Psychoanalysis, New York University; M.A.R., Theology, Westminster Seminary) is clinical psychologist/co-director of the Brookhaven Center for Counseling & Development in Allentown, PA., and is co-director, Society for the Exploration of Psychoanalytic Therapies and Theology.

Please address correspondence regarding this article to Lowell W. Hoffman, Ph.D., Brookhaven Center for Counseling & Development, P. O. Box 425, Fogelsville, PA 18051; lowellwmhoffman@aol.com.