The effectiveness of short- and long-term psychotherapy on personality functioning during a 5-year follow-up

The effectiveness of short- and long-term psychotherapy on personality functioning during a 5-year follow-up

Journal of Affective Disorders 173 (2015) 31–38 Contents lists available at ScienceDirect Journal of Affective Disorders journal homepage: www.elsev...

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Journal of Affective Disorders 173 (2015) 31–38

Contents lists available at ScienceDirect

Journal of Affective Disorders journal homepage:

Research report

The effectiveness of short- and long-term psychotherapy on personality functioning during a 5-year follow-up Olavi Lindfors a,n, Paul Knekt a,b, Erkki Heinonen a, Tommi Härkänen a, Esa Virtala a, the Helsinki Psychotherapy Study Group a,b,c,d,e a

National Institute for Health and Welfare, Helsinki, Finland Biomedicum Helsinki, Helsinki, Finland c Rehabilitation Foundation, Helsinki, Finland d Social Insurance Institution, Helsinki, Finland e Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland b

art ic l e i nf o

a b s t r a c t

Article history: Received 4 August 2014 Received in revised form 21 October 2014 Accepted 22 October 2014 Available online 6 November 2014

Background: Only few randomized trials comparing sustained effects of short- and long-term psychotherapies in personality functioning are available. In this study we compared the effects of two shortterm therapies and long-term psychodynamic psychotherapy on patients’ personality functioning during a 5-year follow-up. Methods: Altogether 326 patients of the Helsinki Psychotherapy Study, with anxiety or mood disorder, were randomly assigned to either short-term psychotherapy of about six months (solution-focused therapy (SFT, n ¼ 97) or short-term psychodynamic psychotherapy (SPP, n ¼ 101)), or to long-term psychodynamic psychotherapy (LPP, n ¼ 128), lasting on average three years. Outcomes in personality functioning (i.e., self-concept, defense style, interpersonal problems, and level of personality organization) were assessed five to seven times using, respectively, questionnaires (SASB, DSQ, IIP) and interview (LPO) during the 5-year follow-up from randomization. Results: Personality functioning improved in all therapy groups. Both short-term therapies fared better than LPP during the first year of follow-up, by faster improvement in self-concept and decrease in immature defense style. SFT also showed more early reduction of interpersonal problems. However, LPP thereafter showed larger and more sustained benefits than SFT and SPP, through greater changes in selfconcept. Additionally, LPP outperformed SFT at the end of the follow-up in IIP and LPO, after adjustment for auxiliary treatment. No differences were noted between the short-term therapies at any measurement point. Limitations: Auxiliary treatment was used relatively widely which limits generalization to exclusive use of short- or long-term therapy. Conclusions: LPP seems to be somewhat more effective than short-term therapies in facilitating longterm changes in personality functioning. & 2014 Elsevier B.V. All rights reserved.

Keywords: Anxiety disorder Mood disorder Personality functioning Psychodynamic Psychotherapy

1. Introduction Personality functioning encompasses relatively pervasive dispositions and characteristic patterns of experiencing and behavior. Psychodynamic conceptualizations of these functions usually cover self-experiential, cognitive-affective, object relational, interpersonal/social, and defensive patterns which represent either vulnerabilities to psychopathology and incurring symptoms, or reflect the capacities to adapt to life changes and challenges


Corresponding author. Tel.: þ 358 29 524 8618. E-mail address: [email protected]fi (O. Lindfors). 0165-0327/& 2014 Elsevier B.V. All rights reserved.

(Applegarth, 1989; Dahlbender and Rudolf, 2006; Sullivan, 1953; Trimboli et al., 2013). These patterns are considered to be founded on developmentally organized psychic structures, which, however, can be modified by new experience, e.g., by psychotherapy. With the help of psychotherapy, the patient is thus expected to become more familiar with her/his dysfunctional behaviour patterns, to understand what they are for and to learn more adaptive forms of personality functioning (Benjamin, 1994), representing thus more fundamental changes than symptomatic recovery alone. As changes in personality functioning require longer to become evident than even chronic distress symptoms (Kopta et al., 1994), personality-related changes are considered to be valuable as markers of sustained therapeutic effects (Blatt et al., 2010), and


O. Lindfors et al. / Journal of Affective Disorders 173 (2015) 31–38

particularly relevant when comparing the effectiveness of shortand long-term therapies. There is only limited evidence on the comparative effectiveness of long-term (duration at least one year) and short-term psychotherapies on personality functioning when treating patients with depressive and anxiety disorders. However, there is growing evidence on the greater benefits of long-term psychodynamic psychotherapy in comparison to shorter therapies when treating complex mental disorders (Leichsenring and Rabung, 2008, 2011; Leichsenring et al., 2013a). As maladaptive personality functioning is a core feature of personality disorders in particular, many of these studies have been focused on long-term treatments of personality-disordered patients. They have shown that improvements extending beyond the end of treatment can be attained in many aspects of personality functioning, e.g. quality of object relations and interpersonal problems, reflecting quality and extent of characteristic behavior patterns (Vinnars et al., 2009), and defense mechanisms (Bond and Perry, 2004; Perry and Bond, 2012). Instead, comparisons between various short-term therapies have mostly found no significant differences across different outcome domains for patients with depressive and anxiety disorder (Abbass et al., 2011; Cuijpers et al., 2010; Driessen et al., 2013; Salzer et al., 2011; Slavin-Mulford and Hilsenroth, 2011), albeit some studies have shown lesser (Leichsenring et al., 2013b; Watzke et al., 2012) and some greater (Kallestad et al., 2010) effects in different aspects of personality functioning after short-term psychodynamic therapy in comparison to other therapies. As far as the authors know, there are only two randomized controlled trials that have compared the effectiveness of shortand long-term psychotherapy in patients with anxiety or depressive disorders on personality functioning, the Helsinki Psychotherapy Study (HPS, Knekt and Lindfors, 2004; Lindfors et al., 2012), and the Norwegian group therapy trial by Lorentzen et al. (2013). In addition, the quasi-experimental Munich Psychotherapy Study (Huber et al., 2012) compared the respective effects in therapies with varying length and intensity. Previous results of the HPS, based on the end-point of the 3-year follow-up after randomization to treatment, showed that changes in self-concept did not differ between the patients randomized to individual long-term psychodynamic psychotherapy (LPP) as compared to patients randomized to short-term psychodynamic psychotherapy (SPP), but LPP did show greater amelioration of self-concept in comparison to patients randomized to brief solution-focused therapy (SFT) (Lindfors et al., 2012). In the other study reporting effectiveness in self-concept, no difference was found between the patients who attended LPP for about three years and those who attended a less intensive 2-year cognitive-behavioral therapy (CBT), after a 3-year follow-up from the end of treatment (Huber et al., 2012). Similarly, the findings on interpersonal problems have been equivocal. The study comparing short- and long-term psychodynamic group therapies (20 and 80 weekly sessions) found no significant difference in the decrease of interpersonal problems at a 3-year follow-up after the beginning of therapies (Lorentzen et al., 2013). However, the study by Huber et al. (2012) showed more beneficial outcome in LPP vs. CBT in more reduced interpersonal problems at the end of therapy and at the 3-year follow-up. Additional information is thus needed on the long-term effects of short- and long-term therapies on various aspects of personality functioning, to allow more reliable conclusions on the potential benefits of LPP. The database of the HPS offers the possibility to extend the follow-up on self-concept changes two years after the end of LPP, and to extend the outcome measurement battery of personality functions. Also, the more typical incomplete treatment response in the short-therapies, as indicated by the patients’ auxiliary treatment after the end of study therapies (Knekt et al., 2011), needs to be acknowledged in order to partial out the long-term effects of nonprotocol treatments.

The aim of this study was to compare the effects of two shortterm psychotherapies and long-term psychodynamic psychotherapy on different aspects of patients’ personality functioning during a 5year follow-up.

2. Patients and methods Patients and methods of the Helsinki Psychotherapy Study have been described in detail elsewhere (Knekt and Lindfors, 2004; Knekt et al., 2008), and are reported only briefly here. The study followed the ethical principles for medical research outlined in the Helsinki Declaration. The patients gave written informed consent, and the ethics council of Helsinki University Central Hospital approved the study. 2.1. Patients and settings A total of 459 eligible outpatients from the Helsinki region were referred to the study between 1994 and 2000. The inclusion criteria included age between 20 and 45 years, the presence of a long-standing (41 year) disorder causing dysfunction in work ability, and a diagnosis of anxiety or mood disorder (American Psychiatric Association, 1994). Exclusion criteria consisted of severe personality disorder, psychotic disorder, bipolar type I disorder, adjustment disorder, substance-related disorder, severe organic disorder, psychotherapy received within the previous two years, and work within psychiatric health care. After 133 patients refused participation, a total of 326 patients were randomly assigned to solution-focused therapy (SFT, 97 patients), short-term psychodynamic psychotherapy (SPP, 101 patients) and to long-term psychodynamic psychotherapy (LPP, 128 patients). After allocation to treatments, four patients assigned to SFT, three assigned to SPP, and 26 assigned to LPP, refused to participate. A total of 42 patients discontinued the assigned treatment prematurely. The mean drop-out in the measurements during 5-year follow-up was 21% in the SFT, 18% in the SPP, and 21% in the LPP group. 2.2. Therapies and therapists SFT is a brief resource-oriented and goal-focused therapeutic approach which helps clients change by constructing solutions (Johnson and Miller, 1994). The technique was based on an approach developed by de Shazer et al. (1986). The frequency of sessions in SFT was flexible, usually one session every second or third week, up to a maximum of 12 sessions, over no more than eight months. The mean length of therapy was 7.5 months (SD ¼3.0). SPP is a brief, focal, transferencebased therapeutic approach which helps patients by exploring and working through specific intrapsychic and interpersonal conflicts. The technique was based on approaches described by Malan (1976) and Sifneos (1978). SPP was scheduled for 20 weekly treatment sessions over 5–6 months. The mean length of therapy was 5.7 months (SD ¼ 1.3). LPP is an open-ended, intensive, transference-based therapeutic approach which helps patients by exploring and working through a broad area of intrapsychic and interpersonal conflicts. The orientation follows the clinical principles of long-term psychodynamic psychotherapy (Gabbard, 2004). LPP was scheduled for two or three sessions per week for up to 3 years. The mean length of therapy was 31.3 months (SD ¼11.9). The therapies were carried out by a total of 55 qualified therapists (Heinonen et al., 2012). Of them, six therapists provided SFT and 12 therapists provided SPP. In these short-term therapies the average years of work experience in the specific therapy was nine for both (range 3–15 and 2–20, respectively). LPP was

O. Lindfors et al. / Journal of Affective Disorders 173 (2015) 31–38

provided by 41 therapists. The average of work experience in LPP was 18 (range 6–30) years. All the therapists had received standard training in respective therapy form. 2.3. Assessments Psychiatric diagnoses, based on the DSM-IV classification of Axis I and Axis II disorders (American Psychiatric Association, 1994) and information on psychiatric history and socio-economic factors were determined at baseline by interviews and questionnaires (Knekt and Lindfors, 2004). Pre-treatment level of psychiatric symptoms was assessed by the Beck Depression Inventory (BDI) (Beck et al., 1961), the Symptom Check List Global Severity Index (SCL-90-GSI) and the Symptom Check List Anxiety Scale (SCL-90-Anx) (Derogatis et al., 1973). Outcomes on personality functioning were measured at baseline, at 7 months, and 1–5 years after the baseline by the 36-item Structural Analysis of Social Behavior (SASB) self-concept (introject) questionnaire (Benjamin, 1996, 2000a) and by the 88-item Defense Style Questionnaire (DSQ, Andrews et al., 1989). Furthermore, the selfrated 64-item Inventory of Interpersonal Problems (IIP, Horowitz et al., 2000) and the interview-based Level of Personality Organization (LPO, Valkonen et al., 2012) scale were measured at baseline, at 7 months, and at the 1-, 3-, and 5-year follow-up occasions. The SASB self-concept score used in the study was the self-directed affiliation (AF) score, which measures the positive-negative dimension of typical self-directed behaviour (Benjamin, 1996). First, in calculating the AF score, the eight cluster scale scores (Self Free, Self Affirm, Self Love, Self Protect, Self Control, Self Blame, Self Attack, Self Neglect) were computed as a mean of the 4 to 5 items belonging to the specific cluster. Then the AF score, indicating the degree to which the cluster scores were oriented around the principal AF vector axis, was calculated with the SASB Intrex program (Benjamin, 2000b). The immature defense style score of the DSQ was used as the indicator of defense style (Andrews et al., 1989). It was calculated on the basis of altogether 46 items covering different aspects of immature defenses (acting out, autistic fantasy, denial, devaluation, displacement, dissociation, isolation, passive aggression, projection, rationalization, splitting, and somatization). The IIP score used in the study was the total sum score, based on the 64 items and covering eight interpersonal problem types, characteristic for the person’s interpersonal behavior (Domineering/Controlling, Vindictive/Self-Centered, Cold/ Distant, Socially Inhibited, Nonassertive, Overly Accommodating, Self-Sacrificing, and Intrusive/Needy) (Horowitz et al., 2000). LPO was a continuous single score assessing the level of personality organization, ranging from normality (score 1.0) to psychotic personality organization (score 7.0) (Valkonen et al., 2012). The quality of the treatment was assessed by using information on the patients’ deviation from the treatment protocol, i.e., withdrawal from treatment, waiting time from baseline examination to the start of study treatment, and discontinuation of study treatment during follow-up. Information on the use of auxiliary psychiatric treatment (psychotherapy, psychotropic medication, and psychiatric hospitalization) during the follow-up period was collected by questionnaire and interview, as well as from nationwide public health registers (Knekt and Lindfors, 2004). A significant proportion (40–74%) of the patients in all three treatment groups used some form of auxiliary psychiatric treatment (psychotropic medication, psychotherapy, or hospitalization) during the 5-year follow-up, in addition to the treatment offered by the study (Knekt et al., 2011). 2.4. Statistical methods The methods used in HPS are presented in detail elsewhere (Knekt et al., 2008; Knekt and Lindfors, 2004) and are only briefly


described here. The statistical analyses were based on linear mixed models (Verbeke and Molenberghs, 1997). Model-adjusted mean levels and mean differences of the outcome measures in the measurement points were calculated using predictive margins (Graubard and Korn, 1999; Lee, 1981). The delta method was applied to calculate confidence intervals (Migon and Gamerman, 1999). Statistical significance was tested with the Wald test. The main analyses were based on the ‘intention-to-treat’ (ITT) sample, and complementary ‘as-treated’ (AT) analyses were performed (Härkänen et al., 2005). The ITT model included the main effects of time, treatment groups, first-order interaction of time and treatment group, and a correction term which included the difference between the theoretical and realized date of measurement. A complementary model further included the outcome variable at the baseline. The AT model further included the variables describing the quality of the treatment and the treatment procedure (i.e. withdrawal from treatment, waiting time from baseline examination to the start of study treatment, and discontinuation of study treatment) and use of auxiliary treatment (i.e. additional psychotherapy, psychotropic medication, and psychiatric hospitalization) during follow-up. Both the ITT and AT models were based on the original data, assuming non-ignorable drop-outs. For further study of this assumption multiple imputation was performed (Rubin, 1987). The statistical analyses were carried out with SAS software 9.2 (SAS Institute, 2008).

3. Results 3.1. Baseline characteristics Most of the patients were young adults and females (Table 1). About half of them were living alone and about 20% had an academic education. The majority of the patients had a mood disorder, being almost exclusively depressive disorders. Fewer than half of the patients had an anxiety disorder, and about one in five a personality disorder. Psychiatric co-morbidity was frequent, in about a half of the patients. The level of psychiatric symptoms and personality functioning scores corresponded to moderate dysfunction in this outpatient sample. Apart from depressive disorders being somewhat less frequent in the SPP group, no significant differences between the treatment groups were noted. 3.2. Effects of short-term therapies and long-term psychodynamic psychotherapy In all the outcome indicators of personality functioning – the SASB AF score, IIP total score, immature defense style score of the DSQ, and LPO score – a statistically significant improvement was observed in all therapy groups during the 5-year follow-up, based on the ITT model (Table 2). During the first year of follow-up the patients in the SFT and SPP groups experienced faster benefits than the patients in the LPP group, in the AF score, in the IIP total score and in the DSQ immature defense style score. Conversely, at the 3- or 4-year follow-up, the AF scores were more improved in LPP than in SFT and SPP, respectively. A similar benefit of LPP appeared in more improved LPO at the 3-year follow-up, in comparison to SFT. No other significant differences were found. The AT model, taking the effects of completeness of the therapy given and of auxiliary treatment into account, however, revealed more additional long-term differences between the treatment groups than the analyses based on the ITT model (Table 3). LPP showed greater changes at the end of the 5-year follow-up, than both SFT and SPP, in AF, indicated by score differences of


O. Lindfors et al. / Journal of Affective Disorders 173 (2015) 31–38

Table 1 Baseline characteristics of the 326 patients by treatment group. Characteristic

Socio-economic variables Age (years)a Males (%) Living alone (%) Academic education (%) Psychiatric diagnosis and symptoms Mood disorder (%) Depressive disorder (%) Anxiety disorder (%) Personality disorder (%) Psychiatric co-morbidity (%) Symptom Check List, Global Severity Index (SCL-90-GSI)a Symptom Check List, Anxiety scale (SCL-90-Anx)a Beck Depression Inventory (BDI)a Personality functions Defense Style Questionnaire (DSQ), immature style scorea Inventory of Interpersonal Problems (IIP) scorea Level of Personality Organization (LPO) scorea Self-concept (SASB), Affiliation (AF) scorea a

Solution-focused therapy (SFT) (n¼ 97)

Short-term psycho-dynamic psycho-therapy (SPP) (n¼ 101)

Long-term psycho-dynamic psycho-therapy (LPP) (n ¼128)

P-value for difference

33.6 (6.6) 25.8 56.7 28.9

32.1 (7.0) 25.7 48.5 19.8

31.6 (6.6) 21.1 49.2 28.1

0.08 0.63 0.44 0.26

86.6 84.5 46.4 18.6 45.4 1.31 (0.50)

78.2 73.3 49.5 24.8 48.5 1.26 (0.53)

88.3 85.9 36.7 12.5 36.7 1.27 (0.55)

0.09 0.03 0.12 0.06 0.17 0.84

1.27 (0.72)

1.25 (0.76)

1.19 (0.68)


18.1 (7.8)

17.9 (7.5)

18.8 (8.3)


3.94 (0.77)

3.92 (0.75)

3.93 (0.69)


91.2 (30.1) 4.20 (0.67) 6.60 (64.3)

86.5 (31.4) 4.24 (0.66) 2.28 (63.6)

82.8 (30.8) 4.14 (0.62) 8.25 (55.4)

0.13 0.51 0.76

Mean (SD).

23.4 (CI 42.7,  3.97) and  21.7 (CI  40.6,  2.86), respectively. Additionally, LPP also showed greater changes at the 5-year follow-up than SFT, in more reduced IIP total score values, indicated by a score difference of 10.0 (CI 0.48, 19.6). Similarly, the LPO scores also were more improved in LPP than in SFT at the 5-year follow-up. No long-term differences emerged in DSQ and no differences were noted between the short-term therapies at any measurement point. Additional analyses carried out using the sub-scores of SASB showed a similar pattern of treatment differences in most of the scores, while in the IIP subscores fewer longterm treatment differences appeared (data not shown).

4. Discussion The findings of this study increase the evidence-base of LPP for patients with depressive or anxiety disorders, by showing its longterm benefits on some areas of personality functioning in comparison to two different types of short-term therapy. Four personality functioning domains were assessed here as main outcomes: selfconcept (SASB AF score), interpersonal problems (IIP total score), defense style (DSQ immature defense style), and personality organization (LPO). Changes in these domains were compared between LPP and the short-term therapy conditions based on the ITT analyses and on the AT analyses. The results of the ITT analysis indicated, first, that improvement in all outcome indicators occurred in all treatment groups during the 5-year follow-up. Second, during the first year of follow-up faster benefits were found in the short-term therapy groups than in the LPP group, except in overall personality organization (LPO), where one would typically not expect rapid changes in perhaps any treatment. In accordance with the goals of the treatment in the short-term therapies, relatively quick improvement of personality functioning – evidenced in self-concept, interpersonal problems, and defense style – should be produced both by the active and focal techniques of SPP (Malan, 1976; Sifneos, 1978), as well as by the goal- and resource-oriented strategies of behavior change in SFT (de Shazer et al., 1986; Iveson, 2002). In contrast, the technique in LPP has intentionally a slower pace of changes, needed for working through (Gabbard, 2004).

Third, the AF score previously found to be more improved in LPP as compared to SFT at the 3-year follow-up (Lindfors et al., 2012) was now found more improved in LPP as compared to SPP at the 4-year follow-up, with a suggestive, non-significant superiority of LPP in comparison to both brief therapies at the 5-year follow-up. Whereas LPP also appeared to outperform SFT on the LPO score at the 3-year follow-up, no differences on it were observed between LPP and SPP at any measurement point. Also, no significant long-term differences were found between LPP and the two brief therapies in the DSQ or in the IIP scores. Thus, the findings based on the ITT analysis provided rather modest evidence on the potential benefits of LPP over short-term therapy for personality functioning, unlike that suggested previously by the few studies comparing LPP with less intensive treatments of heterogeneous disorders (Leichsenring and Rabung, 2011) or by a study on patients with depression where greater intensity or duration of a psychodynamic therapy favored more reduced interpersonal problems or improved self-concept (Huber et al., 2012). Consequently, given that our main findings were only partly in line with previous research, the potential of LPP for producing greater personality change appeared open to question and needing closer investigation. As auxiliary psychiatric treatment was the most typical deviation from the treatment protocol, and was used more frequently in short-term therapies during the 5-year follow-up (Knekt et al., 2011), further AT analyses were considered necessary to report on its potential importance for the effectiveness estimates. The main finding concerning the initial benefits of short-term therapies in self-concept, interpersonal problems and defense style did not, however, change from what was seen in the ITT analysis. Even so, the auxiliary treatment seemed to be partially responsible for the sustained improvement of the short-term therapy patients in the long run, as adjustment for its effect revealed significantly better long-term outcomes in LPP vs. SFT and SPP, in comparison to the initial ITT analysis. In comparison to SFT, LPP produced more positive self-concept, more mature personality organization and fewer interpersonal problems by the end of the 5-year follow-up. In comparison to SPP, more extended long-term benefits of LPP appeared only in the domain of self-concept. These complementary analyses thus highlighted that short-term therapy – without

O. Lindfors et al. / Journal of Affective Disorders 173 (2015) 31–38


Table 2 Mean score levels (s.e.) of the primary psychological functioning variables in treatment groups and mean score differences (95% confidence interval) between the treatment groups,intention-to-treatmodel. Outcome variable Time (year) Mean scores1 (s.e.)

SASB AF score

0 7 12 24 36 48 60

P-value (time)1,3 P-value (group)2,4 IIP 0 Total score 7 12 36 60 P-value (time)1,3 P-value (group)2,4 DSQ, 0 Immature 7 Defensestylescore 12 24 36 48 60 P-value (time)1,3 P-value (group)2,4 LPO 0 Score 7 12 36 60 P-value (time)1,3 P-value (group)2,4

Mean score difference2 (95% confidence interval)

Solutionfocused therapy (SFT) (n ¼97)

Short-term psychodynamic psychotherapy (SPP) (n¼ 101)

Long-term psychodynamic psychotherapy (LPP) (n¼ 128)

6.46 41.2 46.1 42.3 46.0 62.0 60.2

2.65 30.4 41.8 41.5 54.4a 55.2 57.7

(6.01) (7.11) (7.59) (8.04) (7.65) (7.41) (7.83)

9.30 24.6 27.6 53.7a 67.8a 80.7a 78.9

(6.13) (7.22) (7.83) (8.63) (8.09) (7.88) (8.13)

91.1 73.4ab 68.8ab 70.7b 66.7b

(3.14) (3.75) (3.86) (3.82) (3.86)

86.4 73.4ab 69.2b 61.5ab 57.0b

(3.06) (3.68) (3.77) (3.61) (3.75)

82.5 78.7 72.7ab 58.4ab 53.5ab

3.95 3.71a,b 3.58a,b 3.61b 3.54b 3.42b 3.38b

(0.07) (0.08) (0.09) (0.10) (0.10) (0.10) (0.09)

3.92 3.70a,b 3.65b 3.59b 3.51b 3.42b 3.35b

(0.07) (0.08) (0.09) (0.09) (0.09) (0.09) (0.09)

3.92 3.89 3.81 3.47a,b 3.36a,b 3.24a,b 3.29b

4.20 4.15 4.01ab 4.03 4.00

(0.07) (0.07) (0.08) (0.10) (0.12)

4.24 4.04ab 3.97b 3.89b 3.87b

(0.06) (0.07) (0.08) (0.10) (0.12)

4.14 4.04 4.06 3.73ab 3.74b

(5.35) (6.44) (6.97) (7.52) (7.05) (6.76) (6.91) o 001 o 001 (2.73) (3.34) (3.44) (3.31) (3.29) o 001 o 001 (0.07) (0.07) (0.08) (0.08) (0.08) (0.08) (0.08) o 001 o 001 (0.06) (0.07) (0.07) (0.09) (0.10) o 001 0.06




þ 19.8 þ 23.1  8.37  19.4  16.4  15.5

( þ4.55, þ 35.0) ( þ6.44, þ39.7) (  28.1,þ11.4) (  0.78,  37.9) (  34.4, þ 1.71) (  33.6, þ 2.70)

þ 11.3 þ 20.3  7.22  8.83  20.4  15.8

(  3.72, þ26.3) (þ 4.11, þ36.5) (  26.1,þ11.65) (  26.7,þ 9.00) (  37.7,  2.99) (  33.6,þ2.01)

 8.45  2.73 þ 1.15 þ 10.52  3.98  0.32

 11.13  10.2 þ 5.71 þ 6.97

(  3.27, (  1.89, (  3.08, (  2.01,

 19.0)  18.5) þ 14.5) þ 16.0)

 8.08  6.39 0.46 0.93

(  15.8,  0.41) 3.05 (  14.5, þ 1.69) 3.80 (  7.91,þ 8.82)  5.25 (  7.81,þ 9.67)  6.04

(  5.10, (  4.75, (  14.3, (  15.6,

þ 11.2) þ 12.3) þ3.83) þ3.48)

 0.21  0.26 þ 0.11 þ 0.16 þ 0.15 þ 0.06

(  0.05,  0.37) (  0.07,  0.44) (  0.11, þ 0.32) (  0.05, þ 0.38) (  0.07, þ 0.36) (  0.14, þ0.27)

 0.19  0.16 þ 0.11 þ 0.16 þ 0.24 þ 0.07

(  0.35, (  0.34, (  0.09, (  0.05, (  0.02, (  0.13,

 0.04) þ 0.02) þ 0.32) þ 0.37) þ 0.39) þ 0.27)

þ 0.01 0.10 þ 0.11  0.01 þ 0.04 þ 0.01

(  0.15, (  0.09, (  0.22, (  0.23, (  0.19, (  0.21,

þ 0.18) þ 0.29) þ 0.23) þ 0.22) þ 0.26) þ 0.23)

þ 0.05  0.08 þ 0.27 þ 0.21

(  0.11, þ 0.21) (  025, þ0.09) ( þ0.03, þ 0.51) (  0.06, þ0.49)

 0.09  0.15 þ 0.09 þ 0.06

(  0.25, (  0.32, (  0.15, (  0.21,

þ 0.07) þ 0.02) þ 0.32) þ0.34)

 0.14  0.07  0.18  0.15

(  0.31, þ 0.023) (  0.24, þ0.11) (  0.43, þ 0.07) (  0.44, þ 0.14)

(  24.3,þ 7.41) (  19.9, þ 14.4) (  19.1,þ 21.5) (  8.73, þ 29.8) (  22.8, þ 14.9) (  19.7, þ 19.0)

1 Intention-to-treat (ITT) model: adjusted for time, treatment group, the difference between theoretical and realized date of measurement, and first-order interaction of time and treatment group. 2 ITT model adjusted for the baseline level of the outcome measure considered. 3 P-value for time difference for the treatment groups combined. 4 P-value for group difference over time. a A statistically significant change occurred in comparison with the value at the previous time point. b A statistically significant change occurred in comparison with the value at the baseline. Underlined entries have P-values o0.05.

the help of auxiliary treatments – appears not to suffice when the goals are to attain sustained specific benefits in personality functioning, as previously suggested (Leichsenring and Rabung, 2011; Leichsenring et al., 2013a). Accordingly, on the basis of this study and previous research (Perry and Bond, 2012; Lindgren et al., 2010) we can hypothesize that a primary choice of long-term therapy is a viable, relatively secure option when the goals of therapy concern sustained improvement in personality functioning. Another option may be a sequential provision of short-term therapy, followed by continuation phase treatment (Vittengl et al., 2004), though evidence is still lacking on its relative effectiveness in comparison to long-term therapy. Further research is also needed on the patient characteristics that may predict and modify change in personality functioning, and comparison between different outcome domains in short- vs. long-term therapy, in order to define the patient groups particularly in need of long-term therapy. The limited research, based on other outcome dimensions, suggests that the assessment of psychological suitability can be used to improve the fit between the patient and treatment duration (Laaksonen et al., 2013; Lindfors et al., 2014) as well as between the patient and the form of intervention needed (Koelen et al., 2012).

Lastly, no significant differences were found between the shortterm therapies in any of the follow-up occasions, indicating that very different rationales of treatment seem to work equally well when looking at the personality-related outcome averages, as observed previously also in relation to improvement in psychiatric symptoms and work ability (Knekt et al., 2013). However, as only SFT appeared more inferior than LPP, with regard to change in interpersonal problems and the level of personality organization, the psychodynamic approach (Blagys and Hilsenroth, 2000) may be more helpful in facilitating these complex intrapsychic and interpersonal changes more than a purely supportive, solutionfocused technique. As this is the first study comparing these therapies, additional research is needed to verify these hypotheses and to deepen our understanding of these changes and their determinants. The general strengths and limits of the study have been discussed in detail previously (Knekt and Lindfors, 2004; Knekt et al., 2008), and are briefly reviewed and extended below. Major strengths are the relatively large sample, treated as in normal clinical practice by qualified psychotherapists specifically trained for the therapy they were providing (Heinonen et al., 2012); the use of several measurement occasions during


O. Lindfors et al. / Journal of Affective Disorders 173 (2015) 31–38

Table 3 Mean score levels (s.e.) of the primary psychological functioning variables in treatment groups and mean score differences (95% confidence interval) between the treatment groups; as-treated model. Outcome variable

SASB AF score

P-value (time)1,3 P-value (group)2,4 IIP Total score

Time (month) Mean scores1 (s.e.)

Mean score difference2 (95% confidence interval)

Solutionfocused therapy (SFT) (n¼ 97)

Short-term psychodynamic psychotherapy (SPP) (n¼ 101)

Long-term psychodynamic psychotherapy (LPP) (n¼128)

0 7 12 24 36 48 60

3.74 40.1 43.6 39.7 43.6 59.3 57.1

0.86 28.8 40.3 39.6 52.3 53.1 56.1

(10.4) (10.3) (10.5) (10.7) (10.3) (10.2) (10.5)

9.11 24.2 26.8 54.4 68.7s 81.6a 79.4

0 7 12 36 60

97.2 77.6ab 74.0b 75.9b 71.9b

(5.43) (5.32) (5.30) (5.19) (5.23)

92.8 79.0ab 74.8b 67.2ab 62.3b

(5.32) (5.28) (5.31) (5.10) (5.23)

88.1 84.0 77.8ab 62.5ab 57.4ab

3.96 3.71ab 3.60b 3.62b 3.55b 3.43b 3.39b

(0.12) (0.11) (0.12) (0.12) (0.12) (0.12) (0.12)

3.93 3.71ab 3.66b 3.60b 3.52b 3.43b 3.34b

(0.12) (0.11) (0.12) (0.12) (0.12) (0.12) (0.12)

3.90 3.87 3.79 3.45ab 3.36b 3.24ab 3.28b

4.49 4.38 4.26ab 4.27b 4.23b

(0.12) (0.11) (0.11) (0.13) (0.14)

4.54 4.30ab 4.22b 4.12b 4.08b

(0.12) (0.11) (0.12) (0.13) (0.14)

4.42 4.32 4.30 3.95ab 3.95b

P-value (time)1,3 P-value (group)2,4 DSQ, 0 Immature defense 7 Style score 12 24 36 48 60 P-value (time)1,3 P-value (group)2,4 LPO score 0 7 12 36 60 P-value (time)1,3 P-value (group)2,4

(10.6) (10.3) (10.5) (11.0) (10.6) (10.5) (10.7)

(10.1) (9.97) (10.1) (9.89) (9.41) (9.24) (9.48) o 001 o 001 (5.18) (5.14) (5.07) (4.61) (4.67) o 001 o 001 (0.12) (0.11) (0.11) (0.11) (0.11) (0.11) (0.11) o 001 o 001 (0.12) (0.11) (0.11) (0.11) (0.12) o 001 0.06




þ 17.7 þ 18.8  13.8  25.0  22.4  23.4

( þ2.18, þ 33.2) ( þ1.77,þ 35.9) (  33.8,þ6.29) (  43.9,  6.10) (  41.0,  3.71) (  42.7,  3.97)

þ 8.91  17.41  11.81  13.82  25.26  21.73

(  6.05, þ23.9) ( þ 0.98, þ33.9) (  30.8, þ7.23) (  31.9, þ 4.23) (  43.0,  7.51) (  40.6,  2.86)

 8.78  1.43 þ 1.97 þ 11.78  2.90 þ 1.63

(  24.6,þ7.08) (  18.7, þ15.87) (  18.3, þ 22.25) (  7.98, þ 30.3) (  21.7,þ 15.9) (  17.6, þ 20.9)

 10.2  8.24 þ 8.80 þ 10.0

(  18.2,  2.21) (  16.7,þ 0.18) (  0.06, þ 17.7) ( þ0.48, þ 19.6)

 7.15  5.21 þ 2.94 þ 3.00

(  14.8, þ 0.48) (  13.3, þ 2.88) (  5.43, þ11.3) (  6.23, þ12.2)

þ 3.04 þ 3.03  5.86  7.04

(  5.07,þ11.2) (  5.49, þ 11.6) (  14.8,þ 3.06) (  16.5,þ 2.42)

 0.21  0.25 þ 0.12 þ 0.16 þ 0.14 þ 0.05

(  0.37,  0.05) (  0.44,  0.06) (  0.10, þ 0.34) (  0.06, þ 0.38) (  0.09, þ 0.36) (  0.17,þ0.27)

 0.19  0.15 þ 0.12 þ 0.15 þ 0.17 þ 0.05

(  0.35,  0.03) (  0.34, þ0.03) (  0.09, þ0.33) (  0.07,þ0.36) (  0.04, þ0.38) (  0.17,þ 0.26)

þ 0.02 þ 0.09  0.00  0.01 þ 0.03  0.00

(  0.15, þ 0.19) (  0.10, þ 0.28) (  0.22, þ0.22) (  0.24,þ0.21) (  0.19, þ 0.26) (  0.22, þ0.22)

þ 0.05  0.06 þ 0.33 þ 0.32

(  0.12, þ0.21) (  0.23, þ 0.12) ( þ0.09, þ 0.56) ( þ0.04, þ 0.60)

 0.08  0.13 þ 0.13 þ 0.13

(  0.24,þ 0.08) (  0.30, þ0.04) (  0.10, þ0.36) (  0.15, þ0.41)

 0.13  0.08  0.20  0.19

(  0.29, þ0.04) (  0.25, þ0.10) (  0.44, þ 0.04) (  0.48, þ 0.09)


As-treated (AT) model: adjusted for time, treatment group, the difference between theoretical and realized date of measurement, first-order interaction of time and treatment group, and waiting time from baseline examination to start of study treatment, participation at measurement point, participation after randomization, discontinuation of study treatment during follow-up, hospitalization due to psychiatric reason, psychotropic medication and additional psychotherapy. 2 AT model adjusted for the baseline level of the outcome measure considered. 3 P-value for time difference for the treatment groups combined. 4 P-value for group difference over time. a A statistically significant change occurred in comparison with the value at the previous time point. b A statistically significant change occurred in comparison with the value at the baseline. Underlined entries have P-values o 0.05.

the long follow-up time and extending beyond the end-point of all therapies by several years; the assessment of various aspects of personality functioning by reliable measures, suitable for all therapies and not tied to a particular treatment theory or form; the relatively low drop-out rate; and the use of both questionnaires and national health registers in the collection of auxiliary treatment data. There are also certain issues which need to be taken into consideration when interpreting and generalizing the results. First, due to the long duration of LPP, no non-treatment control group could be included for ethical reasons. Consequently, we cannot make conclusions as to the extent the specific study therapies were responsible for the changes observed, although conclusions on the differences in effectiveness between the active treatments can reliably be made. Second, as the patient sample consisted of patients with either depressive or anxiety disorders, with or without comorbid personality disorder, the generalization of the results to single ‘pure’ diagnostic groups is limited. Nevertheless, the patients are largely representative of patients seeking outpatient psychotherapy. Third, as we aimed to study the effectiveness of the treatments in normal clinical practice, no manuals

were included in the psychodynamic therapies and only partial monitoring of therapist adherence was covered. However, all the therapists were qualified and specifically trained for giving the therapy they provided in the study. Fourth, the fact that a randomized clinical trial design was used – though considered optimal for determining effectiveness – does not represent ordinary clinical practice as it overlooks potentially important aspects of the patient’s suitability for the treatment. In this study this may have increased the use of auxiliary treatment specifically in SPP which prefers to select patients according to specific suitability criteria, as well as affected attrition in LPP, as a fifth of the patients withdrew after randomization since they had not self-selected the treatment which requires long-term commitment. Accordingly, adjustments for withdrawal and use of auxiliary treatment were carried out in the AT analyses. Lastly, analyses based on multiple imputation did not notable alter the results. In conclusion, faster changes in most domains of personality functioning occur in short-term therapy, accompanied by relatively frequent auxiliary treatment afterwards. LPP appears to be somewhat more beneficial in providing sustained effects in personality functioning. Further research is needed on the predictors

O. Lindfors et al. / Journal of Affective Disorders 173 (2015) 31–38

of personality-related outcomes to aid in individualized treatment selection for short- and long-term therapy. Conflict of interest None of the authors has any conflicts of interest.

Role of funding source Funding for this study was provided by Social Insurance Institution (SII) and the Academy of Finland (grant no 138876). None of the funding instances had further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Acknowledgements This study was funded by the Academy of Finland, grant no 138876 and the Social Insurance Institution of Finland.

References Abbass, A., Town, J., Driessen, E., 2011. The efficacy of short-term psychodynamic psychotherapy for depressive disorders with comorbid personality disorder. Psychiatry 74, 58–71. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, fourth ed. American Psychiatric Association, Washington DC. Andrews, G., Pollock, C., Stewart, G., 1989. The determination of defense style by questionnaire. Arch Gen Psychiatry 46, 455–460. Applegarth, A., 1989. On structures. J. Am. Psychoanal. Assoc. 37, 1097–1107. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for measuring depression. Arch. Gen. Psychiatry 4, 561–571. Benjamin, L.S., 1996. A clinician-friendly version of the interpersonal circumplex: structural analysis of social behavior (SASB). J. Pers. Assess. 66, 248–266. Benjamin, L.S., 1994. SASB: a bridge between personality theory and clinical psychology. Psychol. Inquiry 5, 273–316. Benjamin, L.S., 2000a. SASB User’s Manual for Short, Medium and Long form Questionnaires. University of Utah, Salt Lake City. Benjamin, L.S., 2000b. The SASB Intrex and Coding Software. University of Utah, Salt Lake City. Blagys, M., Hilsenroth, M., 2000. Distinctive features of short-term psychodynamicinterpersonal psychotherapy: a review of the comparative psychotherapy process literature. Clin. Psychol. Sci. Pract. 7, 167–188. Blatt, S.J., Zuroff, D.C., Hawley, L.L., Auerbach, J.S., 2010. Predictors of sustained therapeutic change. Psychother. Res. 20, 37–54. Bond, M., Perry, J.C., 2004. Long-term changes in defense styles with psychodynamic psychotherapy for depressive, anxiety, and personality disorders. Am. J. Psychiatry 161, 1665–1671. Cuijpers, P., van Straten, A., Bohlmeijer, E., Hollon, S.D., Andersson, G., 2010. The effects of psychotherapy for adult depression are overestimated: a metaanalysis of study quality and effect size. Psychol. Med. 40, 211–233. Dahlbender R.W., Rudolf G., the OPD Task Force, 2006. Psychic structure and mental functioning: current research on the reliable measurement and clinical validity of Operationalized Psychodynamic Diagnostics (OPD) system. In: PDM Task Force, Psychodynamic Diagnostic Manual Alliance of Psychoanalytic Organizations, Silver Spring, pp. 615-662. Derogatis, L.R., Lipman, R.S., Covi, L., 1973. SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol. Bull. 9, 13–28. de Shazer, S., Berg, I.K., Lipchik, E., Nunnally, E., Molnar, A., Gingerich, W., WeinerDavis, M., 1986. Brief therapy: focused solution development. Fam. Process 25, 207–221. Driessen, E., Van, H.L., Don, F.J., Peen, J., Kool, S., Westra, D., Hendriksen, M., Schoevers, R.A., Cuijpers, P., Twisk, J.W., Dekker, J.J., 2013. The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: a randomized clinical trial. Am. J. Psychiatry 170, 1041–1050. Gabbard, G.O., 2004. Long-Term Psychodynamic Psychotherapy: A Basic Text. American Psychiatric Publishing, Washington DC. Graubard, B.I., Korn, E.L., 1999. Predictive margins with survey data. Biometrics 55, 652–659. Härkänen, T., Knekt, P., Virtala, E., Lindfors, O., 2005. A case study in comparing therapies involving informative drop-out, non-ignorable non-compliance and repeated measurements. Stat. Med. 24, 3773–3787. Heinonen, E., Lindfors, O., Laaksonen, M.A., Knekt, P., 2012. Therapists’ professional and personal characteristics as predictors of outcome in short- and long-term psychotherapy. J. Affect. Disord. 138, 301–312. Horowitz, L.M., Alden, L.E., Wiggins, J.S., Pincus, A.L., 2000. Inventory of interpersonal problems. Manual Psychological Corporation: Odessa FL. Huber, D., Zimmermann, J., Henrich, G., Klug, G., 2012. Comparison of cognitivebehavior therapy with psychoanalytic and psychodynamic therapy for depressed patients—a three year follow-up study. Z. Psychosom. Med. Psychother. 68, 299–316. Iveson, C., 2002. Solution-focused brief therapy. Adv. Psychiatr. Treat. 8, 149–156.


Johnson, L.D., Miller, S.D., 1994. Modification of depression risk factors: a solutionfocused approach. Psychother. Theor. Res. Pract. Train. 31, 244–253. Kallestad, H., Valen, J., McCullough, L., Svartberg, M., Høglend, P., Stiles, T.C., 2010. The relationship between insight gained during therapy and long-term outcome in short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Psychother. Res. 20, 526–534. Knekt P., Lindfors O. (Eds.), A randomized trial of the effect of four forms of psychotherapy on depressive and anxiety disorders. design, methods, and results on the effectiveness of short-term psychodynamic psychotherapy and solution-focused therapy during a one-year follow-up. The Social Insurance Institution, Finland, Studies in Social Security and Health, 2004, 77. Knekt, P., Lindfors, O., Härkänen, T., Välikoski, M., Virtala, E., Laaksonen, M.A., Marttunen, M., Kaipainen, M., Renlund, C., 2008. Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychol. Med. 38, 689–703. Knekt, P., Lindfors, O., Renlund, C., Laaksonen, M.A., Haaramo, P., Virtala, E., 2011. Use of auxiliary treatment during a 5-year follow-up among patients receiving short- or long-term therapy. J. Affect. Disord. 135, 221–230. Knekt, P., Lindfors, O., Sares-Jäske, L., Virtala, E., Härkänen, T., 2013. Randomized trial on the effectiveness of long- and short-term psychotherapy on psychiatric symptoms and working ability during a 5-year follow-up. Nordic J. Psychiatry 67, 59–68. Koelen, J.A., Luyten, P., Eurelings-Bontekoe, L.H.M., Diguer, L., Vermote, R., Lowyck, B., Bübring, M.E.F., 2012. The impact of level of personality organization on treatment response: a systematic review. Psychiatry 75, 355–374. Kopta, S.M., Howard, K.I., Lowry, J.L., Beutler, L.E., 1994. Patterns of symptomatic recovery in psychotherapy. J. Consult. Clin. Psychol. 62, 1009–1016. Laaksonen, M.A., Knekt, P., Lindfors, O., 2013. Psychological predictors of the recovery from mood or anxiety disorder in short-term and long-term psychotherapy during a 3-year follow-up. Psychiatr. Res. 208, 162–171. Lee, J., 1981. Covariance adjustment of rates based on the multiple logistic regression model. J. Chron. Dis. 34, 415–426. Leichsenring, F., Rabung, S., 2008. Effectiveness of long-term psychodynamic psychotherapy. J. Am. Med. Assoc. 300, 1551–1565. Leichsenring, F., Rabung, S., 2011. Long-term psychodynamic psychotherapy in complex mental disorders: update of meta-analysis. Br. J. Psychiatry 199, 15–22. Leichsenring, F., Abbass, A., Luyten, P., Hilsenroth, M., Rabung, S., 2013a. The emerging evidence for long-term psychodynamic therapy. Psychodyn. Psychiatry 41, 361–384. Leichsenring, F., Salzer, S., Beutel, M., Herpetz, S., Hiller, W., Hoyer, J., Hueseing, J., Joraschky, P., Nolting, B., Poehlman, K., Ritter, K., Stangier, V., Strauss, U., Stuhldreder, N., B., 2013b. Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. Am. J. Psychiatry 170, 759–767. Lindfors, O., Knekt, P., Virtala, E., Laaksonen, M.A., 2012. The effectiveness of solution-focused therapy and short- and long-term psychodynamic psychotherapy on self-concept during a 3-year follow-up. J. Nerv. Ment. Dis. 200, 946–953. Lindfors, O., Knekt, P., Heinonen, E., Virtala, E., 2014. Quality of object relations and self-concept as predictors of outcome in short- and long-term psychotherapy. J. Affect. Disord. 152-154, 202–211. Lindgren, A., Werbart, A., Philips, B., 2010. Long-term outcome and post-treatment effects of psychoanalytic psychotherapy with young adults. Psychol. Psychother. Theor. Res. Pract. 83, 27–43. Lorentzen, S., Ruud, T., Fjeldstad, A., Høglend, P., 2013. Comparison of short- and long-term dynamic group psychotherapy: randomised clinical trial. Br. J. Psychiatry 203, 280–287. Malan, D.H., 1976. The Frontier of Brief Psychotherapy: An Example of the Convergence of Research and Clinical Practice. Plenum Medical Book, New York. Migon, H., Gamerman, D., 1999. Statistical Inference: An Integrated Approach. Arnold, London. Perry, J.C., Bond, M., 2012. Change in defense mechanims during long-term dynamic psychotherapy and five-year outcome. Am. J. Psychiatry 169, 916–925. Rubin, D.B., 1987. Multiple Imputation for Nonresponse in Surveys. John Wiley, New York. SAS Institute Inc. (2008). SAS Online doc. SAS/STAT User’s Guide, Version 9.2. SAS Institute Inc., Cary, NC. Salzer, S., Winkelbach, C., Leweke, F., Leibing, E., Leichsenring, F., 2011. Long-term effects of short-term psychodynamic psychotherapy and cognitive-behavioural therapy in generalized anxiety disorder. Can. J. Psychother 56, 503–508. Sifneos, P.E., 1978. Short-term anxiety provoking psychotherapy. In: Davanloo, H. (Ed.), Short-term Dynamic Psychotherapy. Spectrum, New York, pp. 35–42. Slavin-Mulford, J., Hilsenroth, M.J., 2011. Evidence-based psychodynamic treatments for anxiety disorders: a review. In: Levy, R.A., Ablon, J.S., Kächele, H. (Eds.), Psychodynamic Psychotherapy Research: Evidence-based Practice and Practice-based Evidence. Humana Press, New York, pp. 117–137. Sullivan, H.S., 1953. The Interpersonal Theory of Psychiatry. Norton, New York, pp. 110–111. Trimboli, F., Marshall, R.L., Keenan, C.W., 2013. Assessing psychopathology from a structural perspective: a psychodynamic model. Bull. Menninger Clin. 77, 132–160. Valkonen, H., Lindfors, O., Knekt, P., 2012. Association between the Rorschach Ego Impairment Index (EII-2) and the Level of Personality Organization (LPO) interview assessment in depressive and anxiety disorder patients. Psychiatr. Res. 200, 849–856. Verbeke, G., Molenberghs, G., 1997. Linear Mixed Models in Practice: A SASoriented Approach. Springer, New York.


O. Lindfors et al. / Journal of Affective Disorders 173 (2015) 31–38

Vinnars, B., Thormählen, B., Gallop, R., Norén, K., Barber, J.P., 2009. Do personality problems improve during psychodynamic supportive-expressive psychotherapy? Secondary outcome results from a randomized controlled trial for psychiatric outpatients with personality disorders. Psychotherapy (Chic.) 46, 362–375. Vittengl, J.R., Clark, L.A., Jarrett, R.B., 2004. Self-directed affiliation and autonomy across acute and continuation phase cognitive therapy for recurrent depression. J. Pers. Assess. 83, 235–247.

Watzke, B, Rüddel, H., Koch, U., Kriston, L., Grothgar, B., Schulz, H., 2012. Longer term outcome of cognitive-behavioural and psychodynamic psychotherapy in routine mental health care: randomized controlled trial. Behav. Res. Ther. 50, 580–587.