Effective Care of Treatment-Resistant Patients in an ISTDP-Based In-Patient Treatment Program
Overall, few studies reported in the literature have focused specifically on non-responders to psychotherapy. Even fewer have specifically selected patients based on previous non-response to treatment and attempted systematic, customized psychological interventions to address their needs. Such studies could yield important information about strategies for overcoming the unfortunate fact that so many do not benefit from psychological treatments. The current study, and the treatment program it examines, was designed and implemented as an attempt to remedy this state of affairs. With the aim of relieving the suffering of patients with repeated non-response to treatment, an intensive, time-limited, residential treatment program was devised.
Using criteria for clinically significant change in symptoms,1 the average recovery rate for formal psychotherapeutic treatments delivered in well-designed trials is approximately 50%.2 Accordingly, approximately half the patients leave treatment with significant clinical symptoms or deteriorate during or after the intervention. In routine care (treatment as delivered outside of organized psychotherapy trials), the rates of recovery are substantially smaller.3 Thus, a large percentage of patients in mental health care can be classified as “treatment-resistant” to psychotherapy. Given this, the development of new approaches specifically designed to aid these patients is of prime importance.
Due to lack of research, it remains unknown whether modifications in treatment format, setting, dose, or content could improve outcome for these patients. Some studies have reported advances in the treatment of these challenging patients. For example, a recent naturalistic study of a 12-week residential, psychodynamic/ existential treatment program designed for treatment-resistant depression has shown promise. Patients in the program improved both interpersonally and symptomatically, and also significantly outperformed a group of matched controls receiving residential treatment as usual.4 Furthermore, a 6-month residential program using an intensive short-term dynamic psychotherapy (ISTDP) approach in the Netherlands has demonstrated large and sustained therapeutic effects with treatment-resistant, personality disordered patients.5 These studies provide some evidence that tailored residential treatment programs may be helpful for patients with treatment-resistant disorders.
An ISTDP format6 was used as the basis for the individual psychotherapy patients received during their residential treatment. According to this model of treatment, psychopathology is understood as the inevitable consequence of failed integration of affect, cognition, and behavior7 related to ruptured attachment bonds. There is a specific focus on the mobilization of warded-off, repressed, or avoided affect associated with these pathogenic ruptures with attachment figures, such that they can be activated and reworked directly within the therapeutic relationship.
Due to a surge in international interest, recent availability of high-quality training, and this model’s clear conceptualization of the phenomena of resistance and consequent failure in treatment, ISTDP7 was selected as the theoretical and technical basis for development of this program. ISTDP is one of the psychotherapy models in the literature that most clearly conceptualizes systematic work with treatment resistance.7,8 This model offers a conceptually integrated intervention system directed at dealing with both conscious and unconscious maneuvers that prevent genuine emotional closeness; minimize strong affect; and leave the patient in a passive, helpless, compliant, or defiant position vis a vis the therapist. Such defensive processes are considered the principal obstacles to therapeutic engagement and improvement, contributing to eventual treatment failure if not identified and challenged.
A number of case series and randomized, controlled trials9 suggest that ISTDP is highly effective in the outpatient treatment of complex and resistant patients. A report from the UK’s Pathfinder project demonstrated that ISTDP achieved good treatment effects in patients who had proven resistant to all other treatment efforts.10 ISTDP has been shown to be effective with patients suffering from treatment-resistant depression,11 chronic somatic conditions, functional movement disorders,12 chronic pain,13 and medically unexplained symptoms (in patients with frequent emergency room visits).14 It has also been found effective in treating people with severe mental disorders in a psychiatric hospital. In this sample, there was a significant reduction in self-reported symptoms/interpersonal problems, along with a significant reduction in need for electroconvulsive therapy.15
The present study was designed to investigate the effectiveness of an ISTDP-based, time-limited residential treatment program for relieving treatment-resistant disorders in a sample of 35 patients. The study examined changes in target complaints, general symptom distress, and interpersonal functioning during and after 8 weeks of residential treatment, as well as at 1 year follow-up. Effect sizes, and the number of cases with clinically significant improvements, are presented. Possible implications for the treatment of treatment-resistant disorders and future research are discussed.
Psychiatric Annals, 2013, 43 (11), 516- 522