Jacques P. Barber - Dynamic Therapies For Psychiatric Disorders (axis I)

Dynamic Therapies for Psychiatric Disorders (Axis I)

Jacques P. Barber & Paul Crits-Christoph

e-Book 2016 International Psychotherapy Institute

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Copyright 1995 Jacques P. Barber & Paul Crits-Christoph

To our children Natalie and Adam, and Alexander, Avery, andNicholas who are going to live in a world that will change even faster than theone we have known

Jacques P. Barber, PH.D.
Assistant Professor, Center for Psychotherapy Research, Department ofPsychiatry, University of Pennsylvania

John Cacciola, PH.D.
Research Assistant Professor, Department of Psychiatry, University of PennsylvaniaMedical School

Katherine Crits-Christoph, PH.D.
Private Practice, Philadelphia; Clinical Assistant Professor, Center forPsychotherapy Research, Department of Psychiatry, University of PennsylvaniaMedical School

Paul Crits-Christoph, PH.D.
Associate Professor and Director, Center for Psychotherapy Research, Departmentof Psychiatry, University of Pennsylvania Medical School

Marylene Cloitre, PH.D.
Director of Psychology Training, Payne Whitney Clinic, Cornell Medical School

Peter L. DeRoche, M.D., C.C.F.P., F.R.C.P.(C)
Assistant Professor, Department of Psychiatry, University of Toronto; Director,Clinic for HIV-Related Concerns, Mount Sinai Hospital, Toronto

Tracy D. Eells, PH.D.
Assistant Professor, Department of Psychiatry and Behavioral Sciences, Universityof Louisville

Jeffrey Faude, PH.D.
Private Practice, Philadelphia; Consultant, Center for Psychotherapy Research,Department of Psychiatry, University of Pennsylvania Medical School

Margaret Fichter, PH.D.
Lecturer, Department of Psychiatry, University of Pennsylvania Medical School

Louise Gaston, PH.D.
Assistant Professor, Department of Psychiatry, McGill University; Director,TRAUMATYS, Psychological Services Inc.

Barbara Goldsmith, PSY.D..
Private Practice, Philadelphia

LEORA HECKELMAN, PH.D.
Supervising Psychologist, Department of Psychiatry, Roosevelt Hospital, NewYork

Anita V. Hole, PH.D.
Clinical Assistant Professor of Psychology, Department of Psychiatry,University of Pennsylvania Medical School

Craig L. Johnson, PH.D.
Director of Psychology and Director, Eating Disorders Program, LaureatePsychiatric Clinic and Hospital, Tulsa

Bertram P. Karon, PH.D.
Professor, Department of Psychology, Michigan State University

Richard P. Kluft, M.D.
Clinical Professor of Psychiatry, Temple University School of Medicine;Director, Dissociative Disorders Program, the Institute of PennsylvaniaHospital, Philadelphia

Jerome D. Levin, PH.D.
Director, Alcoholism Counselor Training Program, New School for SocialResearch, New York

Lester Luborsky, PH.D.
Emeritus Professor of Psychology in Psychiatry, Center for PsychotherapyResearch, Department of Psychiatry, University of Pennsylvania Medical School

David Mark, PH.D.
Private Practice, Philadelphia; Senior Supervisor, Center for PsychotherapyResearch, Department of Psychiatry, University of Pennsylvania Medical School

Jennifer Q. Morse
Research Assistant, Center for Psychotherapy Research, Department ofPsychiatry, University of Pennsylvania Medical School

Carol Popp, m.d., PH.D.
Assistant Professor, Department of Radiology, Emory University

David Rudick, PH.D.
Private Practice, Philadelphia

Randy A. Sansone, M.D.
Associate Professor and Medical Director, Psychiatry Outpatient Clinic,Department of Psychiatry, University of Oklahoma College of Medicine, Tulsa

M. Katherine Shear, M.D.
Associate Professor of Psychiatry, Western Psychiatric Institute and Clinic,University of Pittsburgh Medical Center

Michael A. Teixeira, PH.D.
Private Practice, Lansing; Visiting Assistant Professor, Department ofPsychology, Michigan State University

Anthony Velleco, PH.D.
U.S. Behavioral Health, Philadelphia

Donna Wolf-Palacio, M.S.W.
Private Practice, Philadelphia

George E. Woody, M.D.
Clinical Professor, Department of Psychiatry, University of PennsylvaniaMedical School

Our interest in collecting treatment guidelines for the dynamictherapy of patients with specific diagnoses grew out of our collaborative workas part of the University of Pennsylvania Center for Psychotherapy Research, aclinical research center for the study of psychotherapy funded by the NationalInstitute of Mental Health. Our center's primary aim is to develop and evaluatethe efficacy of psychotherapies tailored to specific populations. In regard todynamic therapies, we were aware of a variety of other clinicians and clinicalresearchers who had also begun the process of tailoring some version of dynamictherapy to a specific population; out of this context the present book emerged.

Financial support was provided in part by grants from the NationalInstitute of Mental Health, the National Institute of Drug Abuse, and from theNational Institute of Mental Health Clinical Research Center. We would like tothank Jo Ann Miller, Steven Francoeur, and Michael Wilde from Basic Books fortheir patience and for their help in completing this book.

CHAPTER 1

Jacques P. Barber, Paul Crits-Christoph, andJennifer Q. Morse

This chapter presents briefly the background and rationale for whatthe book intends to achieve. Developments in psychotherapy research andpractice as well as changes in the patterns of delivery and reimbursement formental health care have led us to conclude, along with many others, thatpsychodynamic psychotherapy is in a precarious situation. What follows are therecent developments responsible for our concerns.

With the emergence of managed health care, such as healthmaintenance organizations (HMOs), and caps on reimbursement for inpatient andoutpatient care, psychotherapists have become more aware of the importance ofbeing recognized by the health alliances as providing a worthwhile,cost-effective service. In general, HMOs and similar managed care organizationsprovide their patients with a small number of low-fee therapy sessions. Theaims of the treatment are mostly targeted at alleviating symptomatic discomfort.It seems more than likely that the emphasis on specific disorders or onspecific symptoms will continue and that therapists will be encouraged to usetreatments that have been shown empirically to be effective for those disordersand symptoms.

There is consensus that psychotherapy in general appears to beeffective (e.g., Smith & Glass, 1977); thus, the general question ofeffectiveness is no longer seen as relevant. Instead, the question has become,"What treatments are effective for what types of patients?" Alongthese lines, researchers on cognitive and behavioral treatments have shown thatbrief therapies can be effective for specific disorders. As an example,cognitive therapy (CT) (Beck, Rush, Shaw, & Emery, 1979) has beenrepeatedly shown to be effective for depression (Dobson, 1989), panic disorders(Clark, Salkovskis, Hackmann, Middleton, Anastasiades, & Gelder, 1991), andopiate addiction (Woody et al., 1983). In fact, CT is as effective aspharmacotherapy in treating depression (see, e.g., Beck, 1993, and Dobson,1989, for reviews) and may be better than medication at preventing relapse(Barber & DeRubeis, 1989). Such efficacy research has already resulted inkey organizations recommending that treatments whose effectiveness has beenempirically demonstrated be the treatments of choice. However, theinterpretation of the research literature by such organizations may be open toquestion. For example, despite the demonstrated efficacy of CT for depression(Dobson, 1989), the American Psychiatric Association (1993) recommends the useof CT for mild to moderate depression only. Although empirical evidence may notalways be sufficient to convince different policy-making groups of the efficacyof any form of psychotherapy, we cannot envision convincing those groupswithout such evidence.