Long-term effects of psychotherapeutic interventions

A review of recent international research.

Long-term effects of psychotherapeutic interventions

   "To society's loss, there is an alarming laxity within the mental health professions when it comes to monitoring, commenting on, and educating the public about what is good therapy, what is negligent behaviour by trained professionals, and what is or borders on quackery."     
 ~ Singer and Lalich, "Crazy" Therapies

Personal therapy for Therapists
Will a therapist be caring, non-abusive, technically proficient, and effective?
Psychotherapeutic work seems closely tied to the therapist's self-knowledge and willingness to self-reflect. In most European countries, only a requisite number of hours of personal therapy is obligatory. In the United States only analytic training institutes and a few graduate programs require a course of personal therapy. At the most commonsense level, a therapist who knows what it is like to be a patient may be more empathic, and may anticipate unstated feelings more readily than a therapist without this first-hand knowledge. The argument is even stronger for therapists who practice traditional psychodynamic therapy, where transference and countertransference are essential treatment tools.
Therapy for Therapists. Should therapists have therapy themselves?

Behaviour therapy

Cognitive-behavioural therapy


Psychodynamic Psychotherapy

Humanistic psychotherapy

Gestalt Therapy

Transactional Analysis

Bioenergetic Analysis

PsychoTrauma Therapy

Somatic Experiencing Therapy

Family Systems Constellations

Eye Movement Desensitization (EMDR)

Scientifically conducted effectiveness studies are rare and inconclusive for most psychotherapeutic interventions. A study by Dr. Martin Seligman [1] from the University of Pennsylvania demonstrated that no specific modality of psychotherapy did better than any other for any disorder. Psychologists, psychiatrists, and social workers did not differ in their effectiveness as treaters; and all did better than marriage counselors and long-term family doctors. Patients whose length of therapy or choice of therapist was limited by insurance did worse.

The first half of the 20th century has seen the development of two major branches of psychotherapy: the behaviourist model postulating the idea that maladaptive behaviour is learned, and thus adaptive behaviour can also be learned, and psychoanalytical schools trying to gain insights into unconscious dynamics behind emotional and behavioural problems.

At their core there is a fundamental disagreement about human nature – about why we suffer, and how, if ever, we can hope to find peace of mind. Psychoanalysts contend that for one thing, psychological pain needs first not to be eliminated, but understood. From this perspective, depression is less like a tumour and more like a stabbing pain in your abdomen: it’s telling you something, and you need to find out what.

Many therapies emerged in Freud’s wake, as therapists struggled to put their endeavours on a sounder empirical footing. From all these approaches – including humanistic therapy, interpersonal therapy, transpersonal therapy, transactional analysis and so on – it’s generally agreed that cognitive behavioural therapy, or CBT, is a most effective technique. It is focused not on the past but the present; on adjusting the unhelpful thought patterns that cause negative emotions.

Most psychotherapy research focuses on the validation of treatment effects for patients with various psychological problems. However, psychotherapy is not always helpful. While the general effectiveness of bona fide psychotherapies is well established, the number of patients who fail to improve or even deteriorate is still problematic (Hansen et al., 2002; Lambert, 2007, 2011, 2013; Warren et al., 2010).

Failure in psychotherapy is a complex topic, and the term has been used for a broad array of disparate unwanted effects, such as attrition, non-response, deterioration, adverse outcomes, harmful or iatrogenic effects, and side effects (Lilienfeld, 2007; Dimidjian and Hollon, 2010; Linden, 2013; Parry et al., 2016). Inadequate treatment choice, the patient’s particular mental conditions, or the therapist’s technical mistakes are typical variables related to unsuccessful and negative outcomes. In recent years, there has also been an increased awareness in the field that the therapists’ individual skills make a significant contribution to the variance in outcome (Baldwin and Imel, 2013; Owen et al., 2015; Hill et al., 2017).

While some therapists are generally more successful than others, most therapists have experienced both therapeutic success and failure in different cases (Okiishi et al., 2003; Wampold and Brown, 2005; Kraus et al., 2011; Baldwin and Imel, 2013). However, therapists often have difficulties in identifying their own shortcomings and are unfamiliar with the methods and criteria for identifying and preventing negative outcomes (Dimidjian and Hollon, 2010; Gold and Stricker, 2011; Hilsenroth et al., 2012; Kächele and Schachter, 2014). Accordingly, we need to learn more about within-therapist differences in order to understand what makes even well-trained psychotherapists fail in some cases (Merten and Krause, 2003; Baldwin and Imel, 2013). Recognition of treatment failures is a characteristic of good therapists and may significantly improve clinical outcomes (Hatfield et al., 2010; Linden, 2013; Budge, 2016).
Frontiers in Psychology 2019

Behaviour therapy
Developed by Ivan Pavlov and without recourse to inner mental states it is based on classical conditioning, or associative learning. Pavlov's famous dogs, began drooling when they heard their dinner bell, because they associated the sound with food. The significance of this approach has been profound, making it one of the pillars of pharmacological therapy. The theory was further developed by John B. Watson and later by B. F. Skinner who claimed to have found a new version of psychological science, which he called the experimental analysis of behaviour. He achieved remarkable success in training animals to perform unexpected responses, at the purely behavioural level.
Behaviourist Learning Theory

Cognitive-behavioural therapy
Exposure therapy was first reported in 1924 by Mary Cover Jones, who is considered the mother of behaviour therapy. Jones used exposure therapy with a boy named Peter to help him overcome his fear of rabbits. In the second half of the 20th century, many therapists coupled behavior therapy with the cognitive therapy of Aaron Beck and Albert Ellis, forming cognitive[3] behavioural therapy (CBT). Of previously established efficacy for depression, CBT also has been applied over the past decade in Britain to the treatment of schizophrenia (Sensky et al, 2000). This approach includes structured and systematic reality testing and belief modification, it highlights the internal inconsistency for lack of evidence for a belief and suggests that patients test alternative explanations with the goal of forming new beliefs. Recent results are encouraging, with patients assigned to CBT showing fewer symptoms as well as less disruption to everyday life.

Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that behaviour therapy and cognitive-behavioural therapy are equally effective for obsessive compulsive disorder (OCD). CBT has been proven to perform slightly better at treating co-occurring depression. Systematic desensitisation has been shown to successfully treat phobias about heights, driving, and insects. Virtual reality treatment has been shown to be effective for a fear of heights; it has also been shown to help with the treatment of a variety of anxiety disorders.
Behavior Therapy and Applied Behavioral Analysis.
How To Rebuild Your Finances After Rehab

First laid out by Sigmund Freud in the late 19th century, psychoanalytic theory has undergone many refinements since his work. Observations led Freud to theorise that the problems faced by hysterical patients could be associated to painful childhood experiences that could not be recalled. The influence of these lost memories shaped the feelings, thoughts and behaviours of patients. Starting with his publication of The Interpretation of Dreams, his theories began to gain prominence regarding psychological treatments. Free association is a technique used in psychoanalysis. Sigmund Freud concluded that the personality consists of three different elements, the id, the ego and the superego. The unconscious is the portion of the mind of which a person is not aware. According to Freud it is the unconscious that exposes the true feelings, emotions, and thoughts of the individual.

In the first fully randomised controlled trial of long-term psychoanalytic psychotherapy ( LTPP) for treatment-resistant depression improvements were modest, but differences emerged from 24 months postrandomisation, with the LTPP group mostly maintaining the gains achieved while the control group appeared to be at greater risk of relapse.
NHS study of long-term psychoanalysis as a treatment for chronic depression.
Therapy Wars: the Revenge of Freud by Oliver Burkeman
The effectiveness of psychoanalysis and psychoanalytic psychotherapy.

Psychodynamic Psychotherapy
With a primary focus to reveal the unconscious content of a client's psyche, Psychodynamic psychotherapy is a form of depth psychology that seeks to explore underlying motives as an approach to various mental disorders, with the belief that the uncovering of these motives is intrinsically healing. Some psychodynamic therapists also draw on Carl G. Jung's ideas of archetypal primordial elements and collectively-inherited unconscious patterns.

Empirical evidence seem to support the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence based.” In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Meta-analyses in 2012 and 2013 come to the conclusion that there is support or evidence for the efficacy of psychodynamic therapy, with outcomes comparable or greater than other kinds of psychotherapy or antidepressant drugs.
Psychodynamic psychotherapy
The effectiveness of psychodynamic psychotherapy.

Humanistic psychotherapy
The person-centred humanistic approach ultimately sees human beings as having an innate tendency to progress towards their full potential. Developed by Carl Rogers person-centred therapy focuses on an individual's self worth and values. Being understood, valued and accepted as a person, without being judged, can help an individual to accept who they are, and reconnect with themselves. This ability can become blocked or distorted by our life experiences - particularly those that affect our sense of value. According to Rogers, the conditions necessary to enable real change are genuine empathic understanding and unconditional positive regard for the client.

In some psychotherapeutic approaches, the therapist and their observations are deemed 'expert'. The person-centred approach moves away from this idea and instead trusts that human beings have an innate tendency to find fulfilment of their own personal potentials. By facilitating this, a person-centred counsellor helps the client recognise their own capacity for self-healing and personal growth. The approach has been found particularly useful in helping individuals to overcome specific problems such as depression, anxiety, personality disorders, eating disorders and alcohol addictions as these issues can have significant impact on self-esteem, self-reliance and self-awareness.

The major theorists considered to have prepared the ground for Humanistic Psychology are Otto Rank, Abraham Maslow, Carl Rogers and Rollo May. Marshall Rosenberg, one of Carl Rogers' students, emphasises empathy in the relationship in his concept of Nonviolent Communication. Humanistic theory has had a strong influence on other forms of popular therapy, including Harvey Jackins' Re-evaluation Counselling. The role of the therapist is to create an environment where the client can freely express any thoughts or feelings; and to listen attentively. While personal transformation may be the primary focus of most humanistic psychologists, many now investigate pressing social, cultural, and gender issues.
Assessing the Humanistic-Existential Model: Strengths and Limitations

Gestalt Therapy
Developed by Fritz Perls, Laura Perls and Paul Goodman, Gestalt therapy is an existential/experiential form of psychotherapy that focuses upon the individual's experience in the present moment. It is a method of awareness practice that considers perceiving, feeling, and acting to be conducive to the therapeutic process. Gestalt therapy rose to widespread popularity during the decade of the 1960s and early 1970s. The objective of Gestalt therapy is to enable the client to become more fully and creatively alive, to become free from the blocks and unfinished business that may diminish satisfaction and fulfillment, and to experiment with new ways of being.

Authenticity by the therapist, instead of assuming a role, false self or persona is a critical component in the gestalt process. Gestalt therapy is distinct because it moves toward action, away from mere talk, and for this reason is considered an experiential approach. Topdog (makes demands) vs. underdog (makes excuses) is a phrase coined by Fritz Perls, to describe a common form of the inner conflict. A form of role-playing, the empty chair technique encourages the acting out of feelings and the exploration of projection, the tendency to make the environment responsible for what originates in the self.
Is Gestalt therapy more effective than other therapeutic approaches?
Comparative Look at the Effectiveness of Adlerian Therapy versus Gestalt Therapy
Gestalt processes explained - Introjection, Projection, Confluence and Retroflection.

Transactional Analysis
As a phenomenological approach Transactional Analysis is a theory developed by Dr. Eric Berne in the 1950s. Berne’s theory was based on the ideas of Freud but were also distinctly different, a dissenting branch of psychoanalysis. Berne mapped interpersonal relationships to three ego-states of the individuals involved: the Parent, Adult, and Child state. He then investigated communications, interactions, games and scripts between those ego states. Transactional analysis considers that an individual's final emotional state is the result of inner dialogue between different parts of the psyche. Bern has also introduced the concept of clear intention or contract—an agreement entered into by both client and therapist to pursue specific changes that the client desires.

Emotional blackmail is a term coined by psychotherapist Susan Forward, about controlling people in relationships and the theory that fear, obligation and guilt (FOG) are the transactional dynamics at play between the controller and the person being controlled. Understanding these dynamics are useful to anyone trying to extricate from the controlling behaviour of another person, and deal with their own compulsions to do things that are uncomfortable, undesirable, burdensome, or self-sacrificing for others.
The OK-Not OK Matrix
Eric Berne's Transactional Analysis - theory development and explanation
A review by Dr K S Kinmond & M A Watkin -Manchester Metropolitan University

Bioenergetic Analysis
Rooted in the work of Wilhelm Reich and developed by Alexander Lowen, Bioenergetic Analysis is based upon the continuity between body and mind[4]. The idea behind current bioenergetic practice is that blocks to emotional expression and wellness are manifested in the body as chronic muscle tensions which are often subconscious. The blocks are treated by combining bioenergetically designed breathing, physical exercises and emotional expressions.

Body psychotherapy seems to be useful for adults suffering from neurotic and psychosomatic disorders. How useful it is for psychotics is unknown at the present time. Targeted body techniques may go beyond our “comfort” zone, to bring consciousness to blocked or suppressed feelings and defense patterns adapted in childhood.
Efficacy of Bioenergetic Therapies and Stability of the Therapeutic Result
Evaluation of the effectiveness of Bioenergetic Analysis

PsychoTrauma Therapy
Traumatic[2] events may be single, continuous, or repetitive incidents that render inadequate one's ability to cope with the resulting feelings. The inability to cope may become apparent weeks to years after the traumatic experience. Physical harm, though often a component of the traumatic event, is not mandatory for the development of psychological traumata. This is especially true for traumata during childhood in general and before memory, in that pre-verbal time of our existence.

Using constellations, the problematic and often invisible dynamics that operate in families, perhaps over many generations, can be revealed. Hidden dynamics within any individual or in any social system can block it flourishing and achieving its purpose. Constellation work can help to shift the blockages by uncovering the reality which is an important step to the healing of traumas. The constellation method engages the client's body, mind and heart so that the healing is not merely an intellectual insight, but an experience that can draw on various sources for integration and solutions.

Evidence supporting the effectiveness of stress debriefing is inconclusive and its indication in the treatment of PTSD remains controversial. Newer techniques, such as "virtual therapy," could offer an inexpensive alternative treatment with potentially global application.
Psychotrauma and effective treatment options.
Constellation of the Intention by Prof. Franz Ruppert

Somatic Experiencing Therapy
Developed by Peter Levine, Somatic Experiencing (SE) aims at relieving and resolving the symptoms of post-traumatic stress disorder (PTSD) and other mental and physical trauma-related health problems. In the 1997 book "Waking the Tiger" he discusses at length his observations of animals in the wild, and how they deal with and recover from life-threatening situations. SE is based on the understanding that symptoms of trauma are the result of a dysregulation of the autonomic nervous system. According to Peter Levine, "Trauma lives in the body, not the event."

Sessions are normally face to face, and involve a client tracking his or her own experience. SE attempts to promote awareness and release physical tension that remains in the aftermath of trauma. This occurs when survival responses like fight, flight or freeze are aroused, but are not fully discharged after the traumatic situation has passed. Techniques include "titration" small amounts of distress experience and "pendulation" oscillation between stress and relief. Somatic Experiencing is useful for shock trauma and developmental trauma.
Why Somatic Experiencing Works for Treating Trauma
Peter Levine on Somatic Experiencing
A Randomized Controlled Outcome Study
Somatic Therapy: What Is It and How Does It Work?

Eye Movement Desensitization and Reprocessing (EMDR) Therapy
A structured therapy that encourages the patient to briefly focus on the trauma memory while simultaneously experiencing bilateral stimulation (typically eye movements), which is associated with a reduction in the vividness and emotion associated with the trauma memories.

Eye Movement Desensitization and Reprocessing (EMDR) therapy (Shapiro, 2001) was initially developed in 1987 for the treatment of posttraumatic stress disorder (PTSD) and is guided by the Adaptive Information Processing model (Shapiro 2007). EMDR is an individual therapy typically delivered one to two times per week for a total of 6-12 sessions, although some people benefit from fewer sessions. Sessions can be conducted on consecutive days.
Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder in Adults

Family Systems Constellations
Developed by German psychotherapist Bert Hellinger, Family Constellations also known as Systemic Constellations and Systemic Family Constellations is an alternative therapeutic method which draws on elements of family systems therapy, existential phenomenology and Zulu attitudes to family. The constellations process is at times awe-inspiring in its reach, profundity and effectiveness, yet there has been criticism of some facilitators who have taken Hellinger’s at times authoritarian facilitation style to heart, and have developed into authoritarian and directive facilitators, forgetting, that the client really is and must always be understood as the best authority on himself, even if much of his ‘knowing’ is not fully conscious.
Ethics, morality and constellations facilitation. by Vivian Broughton

Constellation Work became more differentiated in the last 15 years. Several different schools emerged, beyond any differences in personal style of facilitation:

1) The „Classical“ Family Constellation, the way Bert Hellinger practiced and demonstrated it until the end of the Nineties.
2) Several approaches based in constructivism. Among them, the “Systemic Structural Constellation” by Matthias Varga von Kibed and Insa Sparrer is methodically the most distinct one.
3) The method Hellinger calls “Movement of the Soul”, which was his main modus operandi between 2000 and 2006.
4) The „Spiritual Family Constellation“ or “Going with the Spirit-Mind” or “Movements of the Spirit-Mind”, which Bert Hellinger practices since early 2006 and which he calls “The New Family Constellations”
5) "PsychoTrauma Therapy" Prof. Franz Ruppert has developed a unique way of working with the Constellation method to reveal and resolve the hidden dynamics and effects of transgenerational trauma. Constellation of the Intention addresses the issue of fragmentation caused by trauma, and offers an understanding of the impact that trauma may have, on the individual concerned or the whole family system.
6) "Awareness Play" is a Humanistic-Gestalt-Bioenergetics-Constellation approach that gives equal attention to client and representative, and follows the emotional dynamics of the entire constellation group.
The Art of Family Constellation
Where is Constellation Work Heading to? By Wilfried Nelles
Constellation of Intention by Prof. Franz Ruppert

Vipassana Mindfulness Meditation
In the Buddhist tradition Vipassana means insight into the true nature of reality, into impermanence, unsatisfactoriness and emptiness. Introduced to the west by Mahasi Sayadaw and S. N. Goenka as mindfulness of breathing, body, thoughts, feelings and actions, it has gained further popularity. Mindfulness-based cognitive therapy (MBCT) is a psychological therapy designed to aid in preventing the relapse of depression, specifically in individuals with major depressive disorder.
Mindfulness-based cognitive therapy


The issue of Shame
For a moment let us consider the amount of sustained, dedicated, wise and loving parental support required to bring up a child to be well balanced, considerate, kind and a contributing member of society. Now let us compare this to the amount of loving and sustained therapeutic support available to the vast numbers of damaged, abused, hurt and deprived individuals living even in a prosperous, peaceful and lucky country like Australia.

So from a social intervention point of view it is perfectly understandable that faced with rather limited resources, achieving even modest behavioural modification is a huge task. Achieving visceral realignments on a larger scale is virtually beyond reasonable expectations. This is the background in which shame could be seen as an adaptive social control mechanism.

From the suffering individual’s point of view however, it is a malice.

Guilt is about one’s action. It involves a sense of loss, regret and responsibility as the result of one’s action. In a sense it can be viewed a precursor to shame.

Embarrassment is an emotional state of discomfort with oneself, experienced when having a socially unacceptable act or condition witnessed by or revealed to others. Usually some amount of loss of honour or dignity is involved. Embarrassment usually carries the connotation of being caused by an act that is merely socially unacceptable, rather than morally wrong.

Shame is an intensely disturbing feeling about oneself as a person. It arises when socially and morally unfavoured or disapproved characteristics or actions are exposed or threatened to be exposed to others. Shame is a form of anticipated and internalised social rejection. The roots of the word shame are thought to derive from an older word meaning "to cover"; as such, covering oneself, literally or figuratively, is a natural expression of shame. According to John Bradshaw toxic shame is induced, inside children, by all forms of child abuse. Incest and other forms of child sexual abuse can cause particularly severe toxic shame. According Gershen Kaufman shame is important because no other affect is more disturbing to the self, none more central for the sense of identity. In the context of normal development, shame is the source of low self-esteem, diminished self image, poor self concept, and deficient body-image. Shame itself produces self-doubt and disrupts both security and confidence. It can become an impediment to the experience of belonging and to shared intimacy. It is the experiential ground from which conscience and identity inevitably evolve. In the context of pathological development, shame is central to the emergence of alienation, loneliness, inferiority and perfectionism. It plays a central role in many psychological disorders as well, including depression, paranoia, addiction, and borderline conditions. Sexual disorders and many eating disorders are largely disorders of shame.

Humiliation is the exposed or revealed socially unfavoured or unacceptable characteristic or actions. According to Donald Klein it is the feeling of being put down, made to feel less than one feels oneself to be. Klein explains, "When it is outwardly directed, humiliated fury unfortunately creates additional victims, often including innocent bystanders ... . When it is inwardly directed, the resulting self-hate renders victims incapable of meeting their own needs, let alone having energy available to love and care for others." Humiliation is often used as a way of asserting power and control over an other, and is a common form of oppression and abuse. It is a form of defeat; the inability to compensate, to cover or hide.

Apart from somatic manifestations the common and potentially pathological thread in all of the above is the division of the self. The self turning against the self. More recently Brené Brown has sharpened the focus on the easily confused concepts of toxic shame and healthy shame, by re-labelling them in ways that may feel less open to interpretation/confusion. What has been described as toxic shame is what Brown merely calls shame. Shame, guilt and regret may all have some socially adaptive and self-correcting function, however to call them “healthy” is fraught with danger. They also imply a divided self and emotional disturbance.


[1] Seligman's foundational experiments and theory of "learned helplessness" began as an extension of his interest in depression. Learned helplessness is a psychological condition in which a human being or an animal has learned to act or behave helplessly in a particular situation — usually after experiencing some inability to avoid an adverse situation — even when it actually has the power to change its unpleasant or even harmful circumstance.
[2] Psychological trauma has further broadened its definition. Recent research has revealed that emotional trauma can result from such common occurrences as an auto accident, the breakup of a significant relationship, a humiliating or deeply disappointing experience, the discovery of a life-threatening illness or disabling condition, or other similar situations.
[3] Jean Piaget (1936) was the first psychologist to make a systematic study of cognitive development. His contributions include a theory of child cognitive development, detailed observational studies of cognition in children, and a series of simple but ingenious tests to reveal different cognitive abilities.
[4] Franz Alexander led the movement looking for the dynamic interrelation between mind and body. Together with Freud and Sándor Ferenczi, Alexander developed the concept of autoplastic adaptation. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences.

[5] Awareness Play is a light-hearted, unscripted, interactive, intuition and feeling centred approach to uncovering deeper and freer layers of the self.