Content uploaded by Ole André Solbakken
Author content
All content in this area was uploaded by Ole André Solbakken on Mar 24, 2018
Content may be subject to copyright.
Acta Neuropsychiatrica 2016
All rights reserved
DOI: 10.1017/neu.2016.5
©Scandinavian College of Neuropsychopharmacology 2016
ACTA NEUROPSYCHIATRICA
Symptom- and personality disorder changes
in intensive short-term dynamic residential
treatment for treatment-resistant anxiety
and depressive disorders
Ole André Solbakken
1,2
,
Allan Abbass
3
1
The Department of Psychology, University of
Oslo, Oslo, Norway;
2
Drammen District
Psychiatric Centre, Division for Mental Health
and Addiction, Vestre Viken Health Trust,
Drammen, Norway; and
3
The Centre for
Emotions and Health, Dalhousie University,
Halifax, NS, Canada
Keywords: anxiety; depression; personality
disorder; psychodynamic psychotherapy;
treatment resistance
Ole Andre
´Solbakken, The Department of
Psychology, University of Oslo, Postboks 1094
Blindern, 0317 Oslo, Norway.
Tel : +47 22 84 51 80;
Fax: +47 22 84 50 01;
E-mail: o.a.solbakken@psykologi.uio.no
Accepted for publication January 25, 2016
Solbakken OA, Abbass A. Symptom- and personality disorder changes in
intensive short-term dynamic residential treatment for treatment-resistant
anxiety and depressive disorders.
Objective: The study investigated the effectiveness of an 8-week
intensive residential treatment programme based on principles from
intensive short-term dynamic psychotherapy for patients with known
treatment-resistant anxiety- and/or depressive disorders (mainly with
comorbid personality disorders).
Methods: Patients (N=95) with prior repeated treatment failure were
included. Changes in self-reported target complaints, symptom severity,
and overall interpersonal problems have been presented for these patients
in two previous articles. We now expand upon the existing knowledge by
presenting novel data from a number of important observer-based and
self-reported outcome domains (diagnostic changes on Axis I and II,
changes in overall personality dysfunction, disorder complexity,
medication use, health care utilisation, and occupational activity).
Results: There were pervasive and significant improvements on all
measures during treatment, which were maintained or further improved
during follow-up. Fourteen months after the end of treatment, 46.26% of
patients had recovered in terms of Axis I pathology, 63.79% had recovered
in terms of Axis II pathology, 71.18% had returned to work, and there was
a 28.62% reduction in regular use of psychotropic medications. Health care
utilisation was reduced by 65.55%, and there were large improvements in
disorder complexity and levels of personality dysfunction.
Conclusion: The treatment programme was highly effective for patients with
common and complex treatment-resistant mental disorders. Results are
encouraging for the relatively large number of patients who tend not to benefit
from standard formats of treatment for debilitating psychological problems.
Significant outcomes
∙Patients who met criteria of repeated prior treatment failure for current mental disorder, underwent an
8-week intensive residential treatment programme based on principles from intensive short-term
dynamic psychotherapy.
∙Outcome variables were diagnostic status on Axis I and II, number of personality disorder criteria,
number of comorbid Axis I disorders, use of psychotropic medications, visits with treatment providers,
and occupational status.
∙At follow-up 14 months after the end of treatment, 46.26% had recovered in terms of Axis I pathology,
63.79% had recovered in terms of Axis II pathology, 71.18% had returned to work, there was a 28.62%
reduction in psychotropic medications, health care utilisation was reduced by 65.55%, and there were
large improvements in disorder complexity and personality dysfunction.
1
Limitations
∙The study had a relatively small sample size.
∙There was no way of discerning the effectiveness of separate components of the treatment programme.
∙There was no randomisation of patients to treatment and one or more control conditions, thus
coincidental improvements cannot be completely ruled out.
Introduction
Despite the proven efficacy and effectiveness of
psychiatric and psychotherapeutic treatments for
mental disorders, a large proportion of patients
remains who do not benefit from the treatments they
are provided (1,2). Only about one half of treated
patients in well-designed clinical trials can be
expected to recover in terms of symptomatic levels.
In standard short-term out-patient treatment in
naturalistic settings on the other hand, the numbers
appear to be even more sobering. For example,
Hansen et al. (3) found symptom recovery rates of
only 14.1% in a large sample of 6072 patients across
various out-patient sites in the United States. In the
same sample, a further 20.9% were reliably improved,
whereas as much as 65.0% were unchanged or
deteriorated during the treatment. Whole country data
from the United Kingdom following the implementa-
tion of primarily Cognitive Behavioural Therapy
under the Improving Access to Psychological Therapies
(IAPT) scheme have repeatedly shown only about a
45% response rate to first-line treatments, whereas
55% did not respond or deteriorated. The prevalence
of non-response to standard mental health treatment is
disturbingly large.
Recently, there are encouraging findings emerging
in the literature about the effectiveness of tailored
treatment for patients with treatment-resistant
psychological disorders. Studies are accruing which
indicate that long-term treatment may be more effective
for complex mental disorders than short-term treatment
(4–6). Moreover, evidence is accumulating that
demonstrates the effect of systematic feedback to
patients and therapists on reducing negative- and non-
response to psychiatric treatment (1,7).
There are also recent studies indicating that high-
intensity and relatively short-term residential treatment
may be highly effective for treatment-resistant
populations. For example, Stålseth et al. (8) and
Solbakken and Abbass (2,9,10) have shown that
intensive time-limited, residential treatments are
effective in helping a large proportion of patients
with known treatment-resistant depressive- and
anxiety disorders. Stålseth et al. demonstrated that
a tailored psychodynamic existential 12-week treatment
programme for patients with treatment-resistant
depression and comorbid Cluster C personality
disorder was superior to residential treatment as usual
(TAU) of identical length with matched controls.
Effects on both symptoms and interpersonal problems
were large and sustained a year after treatment.
Solbakken and Abbass (9,10) have shown that an
8-week intensive short-term dynamic psychotherapy
(ISTDP) residential treatment programme specially
designed for patients with treatment-resistant
depressive, anxiety and personality disorders yielded
large effects on target complaints, psychiatric
symptoms and interpersonal problems that were
sustained 14 months after the termination of
treatment. A large proportion of treated patients were
classified as recovered on all of these measures at
termination and follow-up. Furthermore, the treatment
programme vastly outperformed TAU. Promising
results have also been reported by Cornelissen and
Verheul (11) and Cornelissen (12) from a 24-week
residential programme using ISTDP for treating
patients with personality disorders, most of which had
previous treatment but failed to benefit. Once again
effects were large and sustained through follow-up.
Some central limitations of these studies on
residential treatment for treatment-resistant disorders
are their reliance on self-report measures, along with the
use of mainly general indicators of psychopathology as
outcome variables (e.g. general symptom severity,
overall interpersonal functioning, and overall levels of
target complaints). It is important to demonstrate
whether or not the extensive changes reported by the
patients themselves are also reflectedintheevaluations
of external observers. Moreover, diagnostic changes
have not been explored, and specific improvement on
the diagnostic categories targeted by the programmes
should be verified. Similarly, even though all of
these studies primarily include patients with Axis II
comorbidity, none of them have assessed and reported
changes in personality disorders and personality
functioning occurring during and after treatment.
Finally, improvements on other relevant outcome
domains such as use of treatment services and
medications, along with changes in employment
status should be more extensively explored.
The present study addresses these issues and thus
builds on existing research on the effectiveness of
customised, intensive residential treatment for
patients with treatment-resistant disorders. It reports
Solbakken and Abbass
2
changes in observer-based diagnostic status
(including presence of Axis I and II disorders, the
level of Axis I comorbidity, and overall Axis II
severity), along with changes in medication use,
health care utilisation, and employment status during
and after the intensive time-limited residential
treatment programme for patients with repeated
non-response to psychiatric treatment as described
in Solbakken and Abbass (2,10). The present
study sample is comprised of all patients included
in the previous two outcome studies from that
programme.
Aims of the study
The aim of this study is to examine the effectiveness
of an ISTDP, time-limited, residential treatment
programme in a sample of 95 consecutively admitted
patients with treatment-resistant anxiety and/or
depressive disorders, and varying degrees of comor-
bidity on Axis I and II. Effectiveness will be
determined through evaluation of diagnostic changes,
changes in medication use, changes in health care
use, and changes in employment status. The study
longitudinally investigated developments in these
factors at the beginning and the end of 8 weeks of
residential treatment and then again ~60 weeks after
the termination of treatment.
Materials and methods
Procedures
Patients were enlisted among referrals to the
residential treatment facility of the Drammen District
Psychiatric Center in Norway. Referrals came from
local out-patient psychiatric clinics, psychiatric
hospitals in the vicinity, and general practitioners in
the area. Patients were screened for inclusion/
exclusion criteria by an intake team. Eligible
candidates had an evaluation session with a trained
psychotherapist at the unit. Decisions regarding
inclusion were made based on previous treatment
history, diagnostic information, referral information,
and response to intervention in the evaluation
session. Eligible patients were then informed about
the study and invited to participate.
Trained coordinators (psychologists) at the unit
informed and included patients. Trained personnel did
diagnostic evaluations according to the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition
(13). The MINI Neuropsychiatric Interview (14) was
used to assess symptom disorders. The Structured
Clinical Interview for the Diagnostic and Statistical
Manual of Mental Disorders, Axis II, Fourth Edition
(DSM-IV-R/SCID-II) was used to assess personality
disorders (15).
Patients completed a core battery of questionnaires
pre-treatment and in weeks 3 and 5. These forms were
also completed at treatment termination, 6 months
post-treatment, and 14 months post-treatment. One
measure of overall level of target complaints was
administered before every individual treatment
session, at termination and twice after termination.
Diagnostic assessments were completed pre-treatment,
after termination, and at 14-month follow-up.
Treatment model
The ISTDP format described by Davanloo (16,17) and
others (18,19) was used as a theoretical and technical
basis for the programme. This treatment model has
been extensively presented in articles and books. Two
recent books may serve as manualised descriptions for
the individual psychotherapeutic treatment provided;
Co-Creating Change –Effective Dynamic Therapy
Techniques (20) and Reaching through Resistance –
Advanced Psychotherapy Techniques (21). Adapted
versions of the ISTDP model were used to develop and
inform the structure, content and format of all
components of the treatment.
ISTDP has been found clinically and cost-effective
in a wide range of psychiatric samples (10,22).
Furthermore, two meta-analyses of ISTDP studies
have found predominantly large effects across
diverse treatment populations that persist in long-
term follow-up (23,24).
The ISTDP model conceptualises psycho-
pathology as failed integration of affect, cognition,
and behaviour (25–27), with particular emphasis on
the mobilisation of warded off, repressed, or avoided
affect related to pathogenic ruptures to the patient’s
bonds with attachment figures throughout the course
of development (9). The model includes a specific
emphasis on the phenomenon of treatment resistance
and its significant role in treatment failure.
We believe that this model is one approach in the
literature that clearly describes and operationalises
how to evaluate and work productively with patients
who are prone to treatment resistance. The model
includes a number of considerations and interventions
directed at dealing with those conscious and
unconscious manoeuvres patients resort to that
prevent genuine emotional closeness, minimise
strong affect, and place the patient in passive,
helpless, compliant, or defiant positions vis-à-vis the
therapist. These defensive processes are thought to
constitute the principal obstacles to therapeutic
engagement and improvement, contributing to
eventual treatment failure if not identified and dealt
with (9). This same process appears prominent in
Symptom- and personality disorder changes in residential ISTDP
3
resistance to both psychotherapeutic and pharmaco-
therapeutic treatment (28).
The treatment programme and its components
Details of the treatment programme are extensively
described elsewhere and can be accessed there for
interested readers (2,9,10). A summary is presented
here. The programme was organised so that treatment
intensity could be increased radically as compared
with standard care. Moreover, patients were treated in
an in-patient unit to increase the time spent in the
therapeutic setting and the likelihood of completing
treatment. The programme combines individual
psychotherapy, group psychotherapy, psychopharma-
cological treatment (if considered required by the
ward psychiatrist), and a number of therapeutic group
activities including body awareness training, struc-
tured psychoeducational lectures, physical exercise,
psychosocial training, and milieu therapy. A pre-set,
non-negotiable time limit of 8 weeks was provided.
Patients entered the programme in groups of five or
six. They received either one (90 min) or two (45min)
individual ISTDP sessions per week, along with two
group sessions (90 min) per week. There were two
sessions of low-intensity physical exercise (walking) per
week, as well as weekly body awareness training
sessions and psychoeducational lectures dealing with
treatment process according to ISTDP theory. Patients
also took part in weekly art therapy groups centring on
the experience and expression of feelings through
guided production of creative and artistic displays.
Patients were also provided a primary contact among
the unit staff, with whom they were encouraged to
discuss their own personal development and significant
problems experienced in the therapeutic process on a
day-to-day basis. In addition, patients met with the ward
psychiatrist if any issues arose with regard to
medications; these consultations were aimed at
optimising medication regimes, or reducing medication
use if considered sensible by the psychiatrist.
Participants
The programme includes patients with treatment-
resistant anxiety- and depressive disorders with and
without comorbid symptom- and personality dis-
orders. Due to the high prevalence of these disorders,
it is reasonable to assume that this particular group
represents the majority of non-responding or
treatment-resistant referrals (9,10,29).
Inclusion criteria. Adult patients (aged 18–70)
were eligible if they
(A) Satisfied criteria of need for hospitalisation for
psychiatric treatment, including deficient
general functioning and loss of function in
multiple domains (e.g. inadequate self-care,
severe breakdown in relational, occupational,
and/or personal functioning).
(B) Had known history of treatment-resistant
disorder, that is, failure to respond with
symptomatic relief and improved occupational
or interpersonal functioning despite three or
more prior attempts at treatment for the
ongoing disorder. ‘Failure to respond’was
operationalised as subjective report of lacking
improvement and continuing need/wish for
treatment from the patient, along with recent
referral from a treatment provider (psycho-
logist/psychiatrist/general practitioner) that
defined the patient as a non-responder to
previous treatments. The previous treatment
attempts could be either medication efforts
or psychotherapeutic/psychosocial efforts, or
most commonly a combination of both.
(C) Had capacity for taking an ‘intrapsychic
perspective’on their problems in the evalua-
tion session, that is, could regard problems as
the result of personal difficulties in dealing
with feelings, thoughts, and reactions to self/
others.;
All three inclusion criteria had to be fulfilled.
Comorbid symptom- and personality disorders were
permitted, as were psychotropic medications (with
the exception of daily intake of sedatives).
Exclusion criteria. Patients were excluded if satis-
fying one or more of the following:
(A) psychotic disorder (except short, reactive
psychotic episodes);
(B) bipolar disorder type I;
(C) dissociative identity disorder;
(D) addiction of such severity that detoxification
was indicated (after which entering treatment
was possible);
(E) psychiatric disorders secondary to known
medical conditions;
(F) mental retardation;
(G) insufficient command of the Norwegian
language;
(H) acute suicide risk, history of severe acting out, or
other serious problems with impulse control.
Sample characteristics
A total of 95 patients consecutively admitted to the
unit comprised the treatment sample for the study.
Figure 1 shows the flow of patients in the study.
Mean age in the study sample was 39 years
(SD: 10.4, range: 19–62), 60.0% were female.
Solbakken and Abbass
4
A total of 85.3% had diagnoses of affective disorders
(recurrent major depressive episode: 55.8%, major
depressive episode: 17.9%, dysthymia: 27.4%, bipolar
disorder type II: 7.4%). Anxiety disorders were
present in 75.8% (social phobia: 30.5%, agoraphobia:
27.4%, general anxiety disorder: 27.4%, panic dis-
order: 23.2%, post traumatic stress disorder (PTSD):
9.5%; specific phobia: 14.7%). A further 23.2% had
substance-related disorders (alcohol dependency:
17.9%, drug abuse: 5.3%). Somatoform disorders
were diagnosed in 24.2% (hypochondrias: 9.5%, body
dysmorphic disorder: 9.5%, pain disorder: 5.3%).
Finally, 5.3% had eating disorders (bulimia). Mean
number of Axis I diagnosis for patients was 3.12 (SD:
1.75). A total of 61.1% had one or more personality
disorders (Cluster C: 36.8%, Cluster B: 14.7%, Cluster
A: 8.4%, not otherwise specified (NOS): 19.0%). All
patients fulfilled criteria for affective disorder or
anxiety disorder or both.
All participants reported three or more prior
treatments for their current episode of psychological
disorder. In the year prior to entering the programme,
78.9% had received psychotherapy (mean number of
therapy sessions was 27), 73.7% had received
psychopharmacological treatment (54.7% of the
total sample used antidepressants; 21.1% used
anxiolytics; 12.6% used antipsychotics; 9.5% used
sleeping medications; 8.4% used mood stabilisers;
3.2% used pain medication), 37.9% had frequently
consulted their general medical practitioner for their
current psychiatric disorder (mean number of
consultations was 10), 23.8% had received group
psychotherapy (mean number of meetings was 18),
17.1% had been admitted to psychiatric hospital
(mean number of hospitalisations in this
subgroup was three), 5.3% had received services
from community psychiatric teams (mean number
of meetings was 14), and 4.2% had received
Fig. 1. Diagram of patient flow through the project.
Symptom- and personality disorder changes in residential ISTDP
5
psychomotor physical therapy (mean number of
sessions was 11).
Ethics statement
The authors assert that all procedures contributing
to this work comply with the ethical standards of
the relevant national and institutional committees
on human experimentation and with the Helsinki
Declaration of 1975, as revised in 2008.
Therapists and training
Individual therapists. There were a total of nine
therapists providing individual treatments in the
study. All individual therapists are trained and
certified psychologists. Therapists participated in a
3-year core training programme in ISTDP delivered
by internationally recognised tutors before and
partly during the time that data were collected. As
therapists were under training for part of the study
period, particular emphasis was placed on ensuring
treatment adherence and fidelity through weekly
peer supervision, along with internet-based case
supervision of treatment video-recordings every
2–3 weeks by the second author for advanced train-
ing and to verify treatment adherence (30,31). All
cases were reviewed in this process and the treat-
ments delivered were classified by the authors as
adequate in terms of therapist adherence and
competence.
Group therapists. The group psychotherapists were
highly experienced, trained, and certified in
traditional psychodynamic group psychotherapy. They
developed a specific synthesis of ISTDP principles
and traditional group therapeutic principles adhered
to in the group psychotherapy component of the
programme. The group sessions thus integrate
traditional group therapeutic principles (32) with the
ISTDP principles of pressure to feeling, systematic
building of emotional tolerance, and methodical
clarification and challenge to defenses.
The body awareness instructor/physiotherapist was
highly experienced, specialised and certified in
psychomotor physiotherapy. The therapist conducting
art therapy was certified and highly experienced. In
body awareness- and art therapy groups the therapists
were assisted by qualified members of staff. The
members of staff providing milieu therapy were
trained and highly experienced in that format. Peer
supervision for all therapists and members of staff
took place every week. There were four resident
psychiatrists administering medications during the
study period, all highly experienced and certified
clinical specialists.
The therapists delivering non-individual components
attended several case-based workshops on ISTDP.
They were supervised by the individual therapists in
principles of ISTDP while delivering their treatments
and had weekly meetings with each other for discuss-
ing how to implement ISTDP principles in the group
therapy settings and ensure treatment adherence.
Group and individual therapists had two meetings
every week for coordinating treatment across mod-
alities, discuss treatment adherence, and ensure that
therapist actions were consistent with ISTDP
principles.
Assessments
Observer-rated measures. Trained members of staff-
assessed patients with observer-based measures
before hospitalisation, at termination, and 14 months
after termination. The MINI Neuropsychiatric Inter-
view (14) was used for assessing symptom disorders.
The DSM-IV-R/SCID-II (15) was used for assessing
personality disorders and severity of personality
problems.
The MINI Neuropsychiatric Interview. The Mini
International Neuropsychiatric Interview (14) meets
the need for a brief, reliable and valid structured
diagnostic interview for psychiatric disorders. The
MINI contains 120 questions and screens 16 Axis I
and one Axis II DSM-IV-R disorders for 24 current
and lifetime diagnoses. Using branching tree logic,
the MINI has two to four screening questions per
disorder. Additional symptom questions within each
disorder section are asked if the screening questions
are endorsed. Ratings derived from the MINI in the
present study included the presence or absence of
any disorder, presence or absence of specific dis-
orders, and the disorder complexity as evidenced
by Axis I comorbidity (total number of disorders).
Inter-rater reliability estimates were calculated on
the basis of a subset of ten interviews that were
independently rated by the assessors. Cohen’sκfor
the categorical variables ranged from 0.74 to 1.0,
indicating substantial to perfect agreement. The
intra-class correlation (ICC) coefficient for the
continuous disorder complexity variable was 0.90
(ICC, 2.1; (33)] indicating excellent agreement.
DSM-IV-R/SCID-II. The SCID-II (15) is a semi-
structured interview developed for the assessment
of DSM-IV-TR personality disorders. The interview
includes the 11 DSM-IV personality disorders
(including personality disorder NOS) and the
appendix categories depressive personality disorder
and passive-aggressive personality disorder. It care-
fully follows the language of the DSM-IV Axis II
Solbakken and Abbass
6
personality disorders criteria. Scoring is done by
each trait being rated either as absent, subthreshold,
present, or ‘inadequate information to code’.
Traits considered present are then summarised and
diagnoses are indicated when a required number
of traits are present for any given disorder. The
SCID-II was administered by trained interviewers.
Ratings derived from the SCID-II included the
presence or absence of any personality disorder,
presence or absence of specific personality
disorders, and the severity of personality problems
as indicated by the total number of fulfilled Axis II
criteria. Inter-rater reliability estimates were calcu-
lated on the basis of a subset of ten interviews that
were independently rated by the assessors. Cohen’s
κfor the categorical variables ranged from 0.62 to
1.0, indicating good to perfect agreement. The ICC
coefficient for the continuous severity of personality
problems variable was 0.87 (ICC, 2.1; (33)) indicat-
ing excellent agreement.
Self-rated measures. A number of self-rated
questionnaires were completed before the evalua-
tion session, before treatment onset, and throughout
the treatment- and follow-up phases, reflecting
various aspects of patient history and functioning.
Questionnaire domains analysed in the present
study are as follows: (1) amount of treatment taken
(operationalised as number of visits with treatment
providers in the previous year), (2) occupational
status (operationalised as presence or absence of
occupational activity (including occupational train-
ing and studying) for 22.5 h or more per week on
average), and (3) use of psychotropic medications
(operationalised as regular use of specific classes of
psychotropic medications and regular use of any
psychotropic medication).
Statistical analyses
When analysing continuous outcome variables
(number of Axis I disorders, number of Axis II
criteria, number of meetings with treatment providers
in the previous year) multilevel modelling was
applied using linear mixed models in the SPSS/
PASW, version 22.0. The multilevel models con-
tained two levels of analysis representing repeated
measurements over time nested within individuals.
Assessments were treated as fixed occasions and
placed at a constant distance across patients. Before
the analyses, dependent variables were centred so
that intercepts were estimated at the time value of
zero, thus removing problems with interpretation of
intercept values (34). A two-piece linear trajectory
was best suited in the majority of individual cases for
the analyses of number of Axis I disorders and
overall number of Axis II criteria. The first piece
represents the treatment phase; the second piece
represents the follow-up phase. The analyses inves-
tigating change were done by computing a separate
model for each phase that contained the fixed effect
of the linear time variable (time), along with a
random effect of the intercept. This procedure
estimates the magnitude of change on each outcome
variable and tests the significance of those changes.
For the analyses of changes in the number of
treatment provider visits, a one-piece linear model
was computed as this variable only was assessed
before treatment and at 14-month follow-up. The
addition of random slopes did not improve overall fit
to any significant degree for any of the models and
hence were not included.
To further examine the magnitude of change in
these outcomes, effect sizes (ES)-Cohen’sdwere
calculated by dividing estimated change scores by
their corresponding standard deviations. In order not
to underestimate error and inflate effects, estimated
mean changes were divided by the pooled standard
deviations of all relevant measurement points on the
outcome variables. Cohen’s (35) standards for
evaluating the magnitude of ES were utilised,
classifying small effects as d=0.2–0.5; medium
effects as d=0.5–0.8; and large effects as d>0.8.
For dichotomous outcomes (presence of Axis I
disorder, presence of Axis II disorder, occupational
status, and use of psychotropic medications), we
computed results in terms of the percentages of
patients with a particular outcome present or absent
at each assessment point. Differences between
measurement points were then tested for statistical
significance with McNemar χ
2
tests for longitudinal
analysis of related dichotomous variables (36). To
avoid inflating estimates of change, we utilised a
procedure for carrying forward the last known
observation when only one observation existed
within a piece in the multilevel models.
Results
Symptom disorder changes
Changes in symptom disorder status from treatment
onset to termination and 14-month follow-up are
presented in Table 1. There was a highly significant
reduction in the number of patients having any Axis I
disorder from treatment onset to termination and
follow-up. The reduction continued throughout
the follow-up phase with significant reduction
also taking place 14 months after termination
(χ
2
=15.06, p=0.0001). There were substantial
and significant improvements across all of the
affective disorders during treatment. Improvements
Symptom- and personality disorder changes in residential ISTDP
7
generally remained stable during the 14-month
follow-up period with two exceptions: for dysthymia
there was a further significant post-treatment
improvement (χ
2
=3.20, p=0.036), whereas for
recurrent depression there was a significant post-
treatment deterioration as compared with results at
the end of treatment, with six cases that were
recovered at termination relapsing in the 14 months
after treatment (χ
2
=4.17, p=0.020).
Substantial improvements from termination
through follow-up were also seen across all the
anxiety disorders with one exception; PTSD, for
which the absolute number of improved cases (from
nine at the onset of treatment to three at termination
and six at follow-up) was significant during
treatment, but non-significant at the 14-month
follow-up. There were also significant post-
treatment improvements for anxiety disorders in
general (χ
2
=11.08, p=0.0004) and for panic
disorder in particular (χ
2
=6.13, p=0.007).
As for substance-related disorders in general, there
were substantial improvements that were stable over
the follow-up period. For alcohol-related disorders in
particular, changes were very sizable and persistent.
For drug-related disorders there was a significant
reduction from the onset of treatment to termination
with all patients recovering from their addictions.
However, two of the five patients initially satisfying
criteria for drug addiction relapsed in the 14 months
after treatment. Thus, even though the number of
patients with drug-related disorders was more than
halved, the low number of patients with this disorder
in the sample rendered the overall improvement at
the time of 14-month follow-up non-significant.
There was a significant reduction of patients with
somatoform disorders in general from onset to
termination and 14-month follow-up. For particular
somatoform disorders, there was a significant
reduction in the number of patients with
hypochondriasis and body dysmorphic disorder
from onset to termination that persisted in the
14-month follow-up period. For patients with
somatoform pain disorder, there was an absolute
but non-significant reduction from five to three cases
Table 1. Number of patients satisfying criteria for symptom disorder at onset, termination, and 14-month follow-up
Time of measurement
T1 T2 T3
Axis I disorder N%N%χ
2
N%χ
2
Any symptom disorder 95 100.00 69 66.31 24.04** 52 54.74 41.02**
Affective disorders 81 85.26 29 30.53 50.02** 28 29.47 51.02**
Recurrent depression 53 55.79 6 6.32 45.02** 12 12.63 39.02**
Major depressive episode 17 17.89 9 9.47 6.13** 6 6.32 9.09**
Dysthymia 26 27.37 16 16.84 8.10** 11 11.58 13.07**
Hypomania 7 7.37 1 1.05 4.17* 1 1.05 4.17*
Anxiety disorders 72 75.79 41 43.16 29.03** 28 29.47 42.02**
Panic disorder 22 23.16 13 13.68 7.11** 5 5.26 15.06**
Agoraphobia 26 27.37 15 15.79 7.11** 11 11.58 13.07**
Social phobia 29 30.53 14 17.74 13.07** 12 12.63 15.06**
GAD 26 27.37 9 9.47 15.06** 6 6.32 18.05**
PTSD 9 9.47 4 4.21 3.20* 6 6.32 1.33
Specific phobia 14 14.74 4 4.21 8.10** 4 4.21 8.10**
OCD 15 15.79 4 4.21 9.09** 4 4.21 9.09**
Somtoform disorders 19 20.00 10 10.53 7.11** 13 13.68 4.17*
Hypochondriasis 9 9.47 3 3.16 4.17* 3 3.16 4.17*
Body dysmorphic disorder 9 9.47 4 4.21 3.20* 4 4.21 3.20*
Somatoform pain disorder 5 5.26 3 3.16 0.50 6 6.32 0.01
Eating disorders 5 5.26 4 4.21 0.01 5 5.26 0.00
Bulimia 5 5.26 4 4.21 0.01 5 5.26 0.00
Substance-related disorders 19 23.20 6 6.32 11.08** 5 5.26 12.07**
Substance dependence 5 5.26 0 0.00 3.20* 2 2.11 1.33
Alcohol dependence 17 17.89 6 6.32 9.09** 3 3.16 12.07**
Other disorders 7 7.37 2 2.11 3.20* 3 3.16 2.25
ADHD 4 4.21 2 2.11 0.50 3 3.16 0.01
Psychotic disorder 2 2.11 0 0.00 0.50 0 0.00 0.50
GAD, general anxiety disorder; N, number of patients; OCD, obsessive/compulsive disorder; ADHD, attention deficit hyperactivity disorder; T1, before treatment; T2, at the
end of 8 weeks of treatment; T3, 14-month follow-up; χ
2
,χ
2
from McNemar’s test comparing proportions across times of measurement (T2 and T3 compared with T1).
*p<0.05, **p<0.01.
Solbakken and Abbass
8
at termination, and then a non-significant increase to
six cases with the disorder at the time of follow-up.
Similarly, for eating disorders, the treatment appears
to have been ineffective, with the same five patients
satisfying criteria for bulimia at the onset of treatment
and 14 months after termination. The number of
patients with attention deficit hyperactivity disorder
(ADHD) was reduced from four to two and three at
termination and follow-up, respectively, a change that
was non-significant. Finally, the number of patients
satisfying criteria for psychotic disorders dropped from
two to zero from onset through termination and follow-
up. This change even though potentially important,
remained non-significant due to the relative
infrequency of the disorder in the sample.
Personality disorder changes
Changes in personality disorder status from treatment
onset to termination and 14-month follow-up are
presented in Table 2. The overall effectiveness in
reducing the number of patients with personality
disorders was impressive, with almost two-thirds of
the patients with personality disorder at onset no
longer having such disorder 14 months after treat-
ment. Improvements in personality disorder status set
in rapidly, and the main bulk of improvements took
place during the 8 weeks of treatment. There was,
however, a continuing reduction in number of
personality disordered cases from termination to
follow-up (from 26 to 21), which was statistically
significant (χ
2
=3.20, p=0.036).
For Cluster C disorders, in general, improvements
were substantial and significant across the 8 weeks of
treatment. Changes were stable in the 14 months after
termination. For both avoidant and obsessive/
compulsive personality disorder (PD) improvements
were significant and stable 14 months after treatment.
For dependent PD, the number of cases dropped from
five at the onset to three at termination and further to
one at 14-month follow-up, a large reduction in terms
of absolute numbers. This reduction, however,
remained non-significant due to the relatively low
number of cases with this PD in the sample.
Fur Cluster B disorders in general, and those
specific disorder categories within that Cluster which
were represented in the sample, improvements were
substantial and significant, and remained stable
through the follow-up phase.
For Cluster A disorders in general changes were
significant and stable. As for specific Cluster A
disorders in the sample, there was a significant
reduction in number of patients with both Paranoid
and Antisocial PD that persisted throughout the
14-month follow-up period. Interestingly, even though
no patient was diagnosed with schizoid PD at the onset
of treatment, one particular patient was found to satisfy
criteria for this disorder at termination and follow-up.
This was the only patient that deteriorated in terms of
personality functioning during and after the treatment
programme. Finally, for the PD NOS category
improvements were substantial during treatment and
remained stable from termination to follow-up.
Changes in disorder complexity and overall personality
functioning
Changes in disorder complexity (as measured by the
overall number of comorbid disorders on Axis I) and
overall personality functioning (as measured by the
overall number of personality disorder criteria
satisfied) during treatment are presented in Table 3,
changes in these parameters during the follow-up
phase are presented in Table 4.
Disorder complexity was significantly reduced
from an average of 3.14 Axis I disorders at onset to
an average of 1.38 at termination. There was a
continuing and significant improvement in the
follow-up phase with the average number of
disorders dropping further to 1.10 after 14 months.
Overall personality functioning also improved
substantially and significantly during the 8 weeks
of treatment, with the average number of Axis II
criteria dropping from 9.28 at the beginning of
treatment to 5.09 at termination. Once again there
was a significant post-therapeutic change, with
Table 2. Number of patients satisfying criteria for personality disorder at onset,
termination, and 14-month follow-up
Time of measurement
T1 T2 T3
Axis II disorder N%N%χ
2
N%χ
2
Any PD 58 61.05 26 27.37 30.03** 21 22.11 35.03**
Cluster C disorders 35 36.84 17 17.89 16.06** 15 15.78 18.05**
Avoidant PD 27 28.42 13 13.68 12.07** 13 13.68 12.07**
Dependent PD 5 5.26 3 3.16 0.50 1 1.05 2.25
Obsessive/compulsive PD 9 9.47 2 2.11 5.14* 2 2.11 5.14*
Cluster B disorders 14 14.74 3 3.16 9.09** 2 2.11 10.08**
Borderline PD 10 10.52 2 2.11 6.13** 2 2.11 6.13**
Histrionic PD –––– – –– –
Narcissistic PD –––– – –– –
Antisocial PD 7 7.37 1 1.05 4.17* 0 0.00 5.14*
Cluster A disorders 8 8.42 3 3.16 3.20* 3 3.16 3.20*
Paranoid PD 8 8.42 2 2.11 4.17* 2 2.11 4.17*
Schizoid PD 0 0.00 1 1.05 0.01 1 1.05 0.01
Schizotypal PD –––– – –– –
PD NOS 18 18.95 7 7.37 9.09** 6 6.32 10.08**
N, number of patients; T1, before treatment; T2, at the end of 8 weeks
of treatment; T3, 14-month follow-up; PD, personality disorder. χ
2
,χ
2
from
McNemar’s test comparing proportions across times of measurement (T2 and T3
compared with T1).
*p<0.05, **p<0.01.
Symptom- and personality disorder changes in residential ISTDP
9
further reduction in the number of satisfied
personality disorder criteria during the 14-month
follow-up phase dropping to an average of 4.36.
Changes in medication use, occupational status, and health
care utilisation
Changes in medication use (number of patients
routinely using psychotropic medications) and occu-
pational status (number of patients occupationally
active for 22.5 h or more per week) are presented in
Fig. 2. There was a significant reduction in the
number of patients taking medications from onset to
termination (χ
2
=18.05, p=0.0001), which
remained stable 14 months later. As for occupational
status, there was a significant increase in the number
of patients being occupationally active from onset to
termination (χ
2
=11.08, p=0.0004). In the year
after treatment, a further significant increase in the
number of occupationally active patients took place
(z=27.03, p=0.0001), culminating with as much
as 82.1% of patients reporting more than 22.5 h of
work-related activity per week.
Changes in health care utilisation (as measured by
number of reported treatment provider visits in the
previous year) are presented in Table 5. There was a
substantial and significant drop from an average of
34.95 visits in the year before partaking in the
programme to an average of 12.04 in the year
preceding the follow-up interviews. Thus, the
number of treatment provider visits was effectively
cut to about a third of the initial level.
Summary of main findings and presentation of effect sizes
Figure 3 summarises the overall changes in overall
diagnostic status on Axis I and II, whereas Fig. 4
reports the ES for the continuous outcome variables.
As can be seen from Fig. 2, the number of patients
with Axis I disorder was close to halved, whereas the
number of patients with Axis II disorder was cut by
close to two-thirds. ES were consistently large, with
the exception of changes in overall number of
personality disorder criteria, for which the ES was
classifiable as medium at termination and large at the
time of 14-month follow-up.
Discussion
The present study shows that a high-intensity and
relatively short-term residential treatment appears to
be very effective in helping patients with highly
comorbid, treatment-resistant affective- and anxiety
disorders, in terms not only of diagnostic improve-
ments related to the Axis I pathology for which they
were primarily referred, but also in terms of
improving Axis II pathology to a substantial degree
in a short amount of time. Treated patients
experienced considerable reductions in overall psy-
chopathological morbidity, disorder complexity,
personality functioning, medication use, use of
mental health care services, along with considerable
improvements in occupational functioning. In terms
of ES for disorder complexity, overall personality
functioning, and use of mental health care services
effects were generally large, accrued quickly, and
persisted at least 14 months after termination of the
treatment programme.
In terms of recovery rates (as defined by the
number of patients no longer satisfying criteria of
Axis I and II disorder after treatment), effects of the
programme were also highly substantial, with 45.3%
of the patients recovered in terms of Axis I pathology
Table 3. Results of multilevel growth curve analyses: estimates of intercepts and
magnitudes of change in number of Axis I disorders and number of Axis II criteria
from the onset of treatment to termination 8 weeks later
Axis I disorders Axis II criteria
Estimate Estimate
Fixed effects
Intercept 3.14 (0.17)** 9.28 (0.65)**
Time −1.72 (0.17)** −4.19 (0.57)**
Residual 1.30 (0.19)** 15.24 (2.25)**
Variance in intercept 1.29 (0.30)** 24.53 (4.87)**
Variance in slopes – –
AIC 684.32 1168.89
AIC, Akaike information criterion.
Standard errors are in parenthesis. Estimations were done by the method of
restricted maximum likelihood.
*p<0.01, **p<0.05.
Table 4. Results of multilevel growth curve analyses: estimates of intercepts and
magnitudes of change in number of Axis I disorders and number of Axis II criteria
during the 14-month follow-up phase
Axis I disorders Axis II criteria
Estimate Estimate
Fixed effects
Intercept 1.39 (0.15)** 5.09 (0.56)**
Time −0.29 (0.13)* −0.73 (0.30)*
Residual 0.77 (0.11)** 4.32 (0.64)**
Variance in intercept 1.20 (0.24)** 24.56 (3.95)**
Variance in slopes – –
AIC 616.99 1035.79
AIC, Akaike information criterion.
Standard errors are in parenthesis. Estimations were done by the method of
restricted maximum likelihood.
*p<0.01, **p<0.05.
Solbakken and Abbass
10
and 63.8% of the patients recovered in terms of Axis
II pathology when assessed 14 months after
termination of treatment. These are noteworthy
rates for patients with history of non-response to
psychiatric treatments. Based on these figures, it
would seem that the ISTDP-based, time-limited,
residential treatment programme is an approach that
warrants consideration for patients who do not
respond to standard treatment formats. This study
thereby supports the conclusions drawn in two
previous studies of the treatment programme (2,9)
and extends our knowledge base by adding
information on observer-based diagnostic changes,
along with information on psychosocial changes and
changes in use of psychotropic medications. In all
assessment domains of the present study, results
point in the same direction: high-intensity, residential
treatment tailored to the needs of treatment-resistant
patients appears both highly effective and efficacious.
Some of the present findings warrant a more
detailed discussion. First of all, to our knowledge,
this is the first study to demonstrate that high-
intensity residential treatment produce marked
changes at the level of observer-based diagnostic
assessments. We believe this to be an important
addition to the existing literature validating and
consolidating findings from previous studies
(2,8,9,11,12).
It is of interest that almost half of the treated
patients no longer satisfied criteria for any Axis I
Occupationally active
T1 73.7 37.9
T2 52.6 62.1
T3 52.6 82.1
0
10
20
30
40
50
60
70
80
%
Using psychotropic medications
Fig. 2. Changes in medication use (number of patients routinely
using psychotropic medications) and occupational status
(number of patients occupationally active for 22.5 h or more
per week).
Table 5. Results of multilevel growth curve analyses: estimates of intercept and
magnitude of change in number of treatment provider visits in the year before
entering the programme compared with the year after finishing the programme
Treatment provider visits
Estimate
Fixed effects
Intercept 34.95 (2.20)**
Time −22.91 (2.78)**
Residual 286.48 (47.42)**
Variance in intercept 71.28 (42.70)
Variance in slopes –
AIC 1282.44
AIC, Akaike information criterion.
Standard errors are in parenthesis. Estimations were done by the method of
restricted maximum likelihood.
*p<0.01, **p<0.05.
Symptom disorder present Personality disorder present
T1 100.0 61.1
T2 66.3 27.4
T3 54.7 22.1
0
10
20
30
40
50
60
70
80
90
100
%
T1
T2
T3
Fig. 3. Changes in overall diagnostic status on Axis I and II.
Axis I disorders Axis II criteria Treatment provider
visits
T2 1.16 0.71
T3 1.35 0.83 1.23
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Cohen's d
Fig. 4. Estimated effect sizes for disorder complexity, overall
personality dysfunction, and treatment provider visits per year.
Symptom- and personality disorder changes in residential ISTDP
11
disorder 14 months after treatments despite
documented resistance to previous treatment efforts
and the high levels of comorbidity on both Axis I and
II. This may indicate that specific tailoring of the
treatment format to the needs of the resistant patient
in combination with substantial increase in treatment
intensity can be a fruitful path towards providing
more effective psychiatric treatment for the relatively
large number of patients who do not benefit
adequately from standard treatment formats.
The treatment programme was very effective in
alleviating those disorders that were prime targets of
the intervention, that is, affective and anxiety
disorders. Looking at the numbers, we see that
~65% of patients with affective disorders at the onset
of treatment no longer had such disorders after
8 weeks of treatment, a change that was stable at
14-month follow-up. For patients with anxiety
disorders ~45% were recovered at termination
increasing to about 60% at 14-month follow-up.
The programme appears to have been very effective
for somatoform disorders and substance-related
disorders as well, with ~75% of patients with
substance-related disorders and about 30% of
patients with somatoform disorders being recovered
in terms of such disorder 14 months after treatment.
Effectiveness was uniformly high across discrete
affective- and anxiety disorder categories with the
exception of PTSD, where the effect did not persist
after treatment (even though 33% of patients with
PTSD at the onset of treatment no longer satisfied
criteria for that disorder at 14-month follow-up).
Despite the lack of a significant effect, we cannot
decisively conclude that the treatment programme is
not effective for PTSD, as the number of patients
with this disorder in the sample was very restricted.
The same reasoning applies to three of those five
other discrete diagnostic categories that were studied
for which no significant and persisting effect of
treatment was found (substance dependence, ADHD,
and psychotic disorders). These disorders were all so
rare in the sample, that although there was a fairly
large relative reduction in the numbers of patients
having those disorders during and after treatment, it
is close to impossible to have a statistically
significant effect. For these disorders, we therefore
conclude that further research is needed in order to
evaluate the effectiveness of high-intensity
residential treatment for these patient groups.
For two disorders, however, we believe we must
conclude that the present programme was not
effective: bulimia and somatoform pain disorder.
For these two, there were no tendencies towards
improvement in the sample. Rather numbers of cases
with these disorders remained highly stable. Why
these two disorders were not responsive to the
treatment is not clear. It may be, at least for bulimia,
that the treatments did not include sufficient focus on
relevant behaviours. For pain disorder, the result is
more puzzling, as ISTDP treatments usually focus
systematically on reducing psychogenic pain
conditions whenever such symptoms appear in-
session. It may, however, be that such symptoms
were relegated to the background, whereas affective-
and anxiety-related symptoms were addressed more
comprehensively, as these were the primary causes of
referral to the programme.
The addition of observer-based data on personality
disorders and personality dysfunction is an important
aspect of the present study, as patients with treatment-
resistant Axis I disorders commonly display personality
problems that likely interfere with treatment efforts. It is
notable that so many patients recovered from their
personality disorders within the relatively short time
frame during which treatment was provided. This gives
credence to the notion that increased treatment intensity
and residential treatment delivery may be highly
valuable to personality disordered patients.
The effectiveness of the programme for personality
disorders is not so surprising in as much as the
treatment model extensively focusses on altering
characterological aspects of the patients’ways of
dealing with affect when activated. However, it is
striking that effects were so rapid to set in (within
8 weeks). This partly indicates that personality
disorder problems may be more swiftly changeable
than commonly thought. It raises questions about the
overall stability of personality disorders as has been
noted in a number of studies in recent years (37).
Moreover, it raises interesting questions about the
interrelatedness of treatment-resistant Axis I pathology
and comorbid personality disorders. Whether the
resolution of resistant Axis I pathology clears the
path for resolution of personality disorder problems, or
resolution of said personality problems clears the path
for reducing treatment-resistant symptom states, or if
they are best addressed in concert, is an area worth
investigating in the future. We note that the
programme appears to be highly effective for all
three PD Clusters, indicating that transdiagnostic
treatment formats as the ISTDP-based model may be
well suited also for PD treatment. This is of interest as
many contemporary treatments for PDs appear to be
designed for specific PDs rather than PDs in general
(e.g. schema-focussed therapy, mentalisation-based
therapy, dialectic behaviour therapy, etc.). On a
related note, the findings of the present study and
previous studies of this treatment programme indicate
that a transdiagnostic treatment model is well suited
for most Axis I and II disorders.
As far as we know, this is the first study to
document substantial changes in the level of disorder
Solbakken and Abbass
12
complexity and overall personality functioning for
patients with treatment-resistant disorders. As both of
these factors are likely to impede upon the
effectiveness of treatment (38), it is interesting to
see the extent to which they themselves are amenable
to psychotherapeutic change. There were substantial
changes in both of these domains during and after
treatment, demonstrating that patients in the sample
left treatment not only less complex in terms of any
remaining core Axis I pathology, but also with
considerably less personality problems overall. One
may speculate that these changes in themselves are
important for the future prognosis of these patients.
For example, it may be that future treatment needs
can be sufficiently resolved by standard formats of
treatment if improvements in disorder complexity
and personality functioning remain reasonably stable
after treatment. Future research should address
whether relapse in treatment-resistant patients tends
to imply full blown relapse into prior functioning
both regarding personality dysfunction and disorder
complexity, or if rather relapses are more
circumscribed following such treatment as found in
the present study.
When it comes to changes in use of psychotropic
medications, we found a reduction of ~ 30% in the
proportion of patients using such medications from
treatment onset to termination that remained stable
through follow-up. This may indicate that psychotropic
medications do not contribute to recovery in patients
with treatment-resistant and complex disorders in a
relatively large number of cases. Future research
should address how medication reductions during
treatment are related to outcome and maintenance of
gains with these patients. It is our experience that these
complex and resistant cases often are offered excessive
amounts of medication that are often not tested and
proven effective with this population.
In terms of both reductions in health care
utilisation and increases in occupational activity
effects were impressive. The number of visits with
treatment providers was cut by about 65% when
comparing the year before and the year after
treatment. This reduction, we believe, can probably
be taken as an indication of increased self-reliance.
Paradoxically, we believe that it also is a sign of
reduced passivity in dealing with one’s mental
illness. It is our distinct impression that many of
the patients arriving at the programme tended to
passively wait for therapists to come up with
solutions rather than an active working on one’s
own behalf towards improvement. The reduction in
the use of health care services also corresponds to
significant reductions in costs associated with health
care after treatment. Future research should
specifically examine the overall cost-effectiveness
of programmes as the one currently under study. Our
findings, however, corroborate other studies of the
ISTDP model indicating such treatment may
relatively rapidly pay for itself by reducing later
treatment costs (22).
The number of patients being occupationally
active increased from onset of treatment to the time
of 14-month follow-up by ~ 115%. Thus, at the final
measurement point >80% of treated patients were
occupationally active. This improvement has a
number of implications. It corroborates the notion
of reduced passivity and reliance on others in the
patient sample. It demonstrates an increased level of
general functioning that extends itself meaningfully
into the everyday life of the patients. Finally, it
implies substantial savings in social welfare expenses
adding substantially to the cost-effectiveness of the
treatment programme (22).
For a number of the outcome variables we found
significant post-treatment improvements. Specifically,
post-treatment gains were demonstrated for the
proportion of patients having any Axis I disorder,
dysthymic disorder, anxiety disorders in general, panic
disorder, personality disorder, Axis I disorder
complexity, overall personality dysfunction, and
occupational activity. Such diverse converging effects
are highly unlikely to be coincidental, especially over a
short 8-week time frame. It also is in line with a meta-
analysis of short-term psychodynamic psychotherapy
studies that found a significant growth in personality
measure gains in follow-up (39).
The strengths of the study are as follows. Treatment
was delivered in a naturalistic setting increasing the
ecological validity of findings: the methods and setting
of the study closely reflect real-world circumstances (10).
The sample size is relatively large. All patients
had comprehensive evaluations and had confirmed
treatment-resistant disorders before intervention.
Drop-out rates were remarkably low. The study
included observer-rated assessments of diagnoses on
both Axis I and II unlike any previous study on
treatment-resistant disordered populations. It used
multiple outcome measures representing a number of
central domains not previously examined with this
population and type of treatment, along with an intention
to treat paradigm increasing the reliability and validity
of findings. Analyses of both continuous and
dichotomous outcome variables were done by state of
the art methodology.
Limitations
There was no randomisation of patients to the
treatment and some other relevant condition. Chance
improvements can therefore not be entirely ruled out.
Still, the limited treatment effects experienced by the
Symptom- and personality disorder changes in residential ISTDP
13
patients in previous treatments make coincidence less
likely as the source of improvements. Moreover, in a
previous study from the programme including a
subset of the patients analysed here, time on a wait-
list control condition had minimal impact on the
patients’problems (10).
The design of the study makes it impossible to
determine the extent to which separate components of
the treatment programme are effective. Furthermore,
we cannot determine their individual contributions to
the overall outcome. It is thereby difficult to ascertain
how much of the benefits were the result of the ISTDP
therapy delivered versus other components or
combinations. Furthermore, it is not possible discern
the impact of other factors such as compassion, care,
support, companionship with other patients, contact
time with treatment providers, and so on.
The follow-up is relatively short. Even though
14 months constitutes a long follow-up phase in
comparison with most studies in the literature (1), it
is still too brief to inform us thoroughly about the
long-term effects of the treatment provided. As
suggested by Solbakken and Abbass (10)
substantially longer follow-up is of special interest
in the study of treatment-resistant disorders, as
relapse rates for such disorders probably are higher
than would otherwise be expected.
Another limitation is that there were no quantitative
measures of adherence of various treatment
modalities. Still, a number of procedures were
undertaken to verify adherence and competence
across different treatment components. These
included case review (video-based) by the second
author, regular meetings to discuss adherence and
harmonise treatment across modalities, along with
regular supervision.
Future studies in this domain should include
randomised assignment of patients with treatment-
resistant disorders to intensive residential treatment
and TAU. Studies also need to compare the present
treatment programme (and programmes like it) with
other treatment models. Examining the relative
effectiveness of intensive residential treatments and
out-patient treatments for treatment refractory
disorders would be important. Designs that help
differentiate the effects of different components of
the treatment programme would also be informative.
Conclusion
The residential treatment programme based on
principles from ISTDP with an 8-week time-limit
was effective in reducing Axis I and II pathology,
personality dysfunction, use of mental health care
services, use of psychotropic medications, and
increasing occupational activity in patients with
common treatment-resistant disorders. Gains were
consistently sustained or further improved 14 months
after the end of treatment. These results corroborate
previous findings on the effectiveness of high-
intensity, short-term residential treatment for
treatment-resistant disorders (2,8,10,11,12) and
add to the existing literature by demonstrating
effectiveness in terms of observer-based diagnostic
characteristics and measures of health care utilisation
and psychosocial functioning. The results are
encouraging and provide hope for a relatively large
group of patients who tend not to benefit adequately
from standard formats of treatment for their incapa-
citating psychological problems.
Acknowledgements
The authors would like to thank staff and patients at
Unit E of the Residential Facility at DPS Drammen,
Vestre Viken Health Trust. The authors also thank all
members of staff at the Residential Facility and DPS
Drammen for their contributions.
Authors’contributions: O.A.S. participated in the
planning, design, implementation, data collection,
data analyses, interpretation of data, as well as taking
main lead in the drafting and later revision of the
article. A.A. participated in the planning, design,
implementation, supervision of study therapists,
interpretation of data, and contributed to the
drafting and later revision of the article. Both
authors approved the final draft.
Financial Support
The study received no external grants or funding and
was financed as an integral part of day-to-day
running at the hospital unit where treatment was
delivered.
Conflicts of Interest
The authors acknowledge bias in favour of the
intensive short-term dynamic psychotherapy
treatment model examined in this study as they are
practitioners and teachers of.
References
1. LAMBERT MJ. The efficacy and effectiveness of
psychotherapy. In: Lambert MJ, editor Bergin and
Garfield’s Handbook of Psychotherapy and Behavior
Change, 6th edn. New York: Wiley, 2013; p. 169–219.
2. SOLBAKKEN OA, ABBASS A. Effective care of treatment-
resistant patients in an ISTDP-based in-patient treatment
program. Psychiatr Ann 2013;43:516–522.
3. HANSEN NB, LAMBERT MJ, FORMAN EM. The psychotherapy
dose-response effect and its implications for treatment
delivery services. Clin Psychol Sci Pract 2002;9:329–343.
Solbakken and Abbass
14
4. LEICHSENRING F, RABUNG S. Long-term psychodynamic
psychotherapy in complex mental disorders: update of a
meta-analysis. Br J Psychiatry 2011;199:15–22.
5. GIESEN-BLOO J, VAN DYCK R, SPINHOVEN P et al. Outpatient
psychotherapy for borderline personality disorder-
randomized trial of schema-focused therapy vs.
transference focused therapy. Arch Gen Psychiatry 2006;63:
649–658.
6. BATEMAN A, FONAGY P. Randomized controlled trial of
outpatient mentalization-based treatment versus structured
clinical management for borderline personality disorder. Am
J Psychiatry 2009;166:1355–1364.
7. AMBLE I, GUDE T, STUBDAL S, JUST ANDERSEN B, WAMPOLD BE.
The effect of implementing the Outcome Questionnaire-45.2
feedback system in Norway: a multisite randomized clinical
trial in a naturalistic setting. Psychother Res 2014;7:1–9.
8. STÅLSETH G, GUDE T, RØNNESTAD MH, MONSEN JT.
Existential dynamic therapy (‘VITA’) for treatment-
resistant depression with Cluster C disorder: matched
comparison to treatment as usual. Psychother Res 2012;22:
579–591.
9. SOLBAKKEN OA, ABBASS A. Implementation of an intensive
short-term dynamic treatment program for patients with
treatment-resistant disorders in residential care. BMC
Psychiatry 2014;14:12.
10. SOLBAKKEN OA, ABBASS A. Intensive short-term dynamic
residential treatment program for patients with treatment-
resistant disorders. J Affect Disord 2015;181:67–77.
11. CORNELISSEN K, VERHEUL R. Treatment outcome of
residential treatment with ISTDP. AD HOC Bull Short
Term Dyn Psychother 2002;6:14–23.
12. CORNELISSEN K. Long term follow up of residential ISTDP
with patients suffering from personality disorders. AD HOC
Bull Short Term Dyn Psychother 2014;18:20–29.
13. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV).
Washington, DC: American Psychiatric Association, 1994.
14. SHEEHAN DV, LECRUBIER Y, SHEEHAN KH et al. The Mini-
International Neuropsychiatric Interview (M.I.N.I.): the
development and validation of a structured diagnostic
psychiatric interview for DSM-IV and ICD-10. J Clin
Psychiatry 1998;59:22–33.
15. FIRST MB, SPITZER RL, GIBBON M, WILLIAMS JBW, BENJAMIN
L. Structured Clinical Interview for the DSM-IV Axis II
Personality Disorders (SCID-II). (Version 2.0). New York,
NY: Biometric Department, New York State Psychiatric
Institute, 1994.
16. DAVANLOO H. Unlocking the Unconscious. Chichester:
Wiley, 1990.
17. DAVANLOO H. Intensive Short-Term Dynamic
Psychotherapy: Selected Papers of Habib Davanloo, M.D.
Chichester: Wiley, 2000.
18. DELLA SELVA P. Dynamic assessment of ego functioning in
Davanloo’s ISTDP. In: Ten Have de Labije J, editor The
Working Alliance in ISTDP: Whose Intrapsychic Crisis?.
Amsterdam: VDKP, 2001; p. 1–40.
19. ABBASS A, BECHARD D. Bringing character changes with
Davanloo’s intensive short term dynamic psychotherapy.
Ad Hoc Bull Short Term Dyn Psychother 2007;11:26–40.
20. FREDERICKSON J. Co-Creating Change: Effective Dynamic
Therapy Techniques. Washington, DC: Seven Leaves Press,
2013.
21. ABBASS A. Reaching Through Resistance: Advanced
Psychotherapy Skills. Kansas City, MO: Seven Leaves
Press, 2015.
22. ABBASS A, KATZMAN J. The cost-effectiveness of intensive
short-term dynamic psychotherapy. Psychiatr Ann 2013;
43:496–501.
23. TOWN JM, DRIESSEN E. Emerging evidence for Intensive
Short-Term Dynamic Psychotherapy with personality disorders
and somatic disorders. Psychiatr Ann 2013;43:502–507.
24. ABBASS A, TOWN J, DRIESSEN E. Intensive short-term dynamic
psychotherapy: a systematic review and meta-analysis of
outcome research. Harv Rev Psychiatry 2012;20:97–108.
25. SOLBAKKEN OA, HANSEN RS, HAVIK OE, MONSEN JT. Affect
integration as a predictor of change: affect consciousness and
treatment response in open-ended psychotherapy. Psychother
Res 2012;22:656–672.
26. SOLBAKKEN OA, HANSEN RS, HAVIK OE, MONSEN JT.
Assessment of affect integration: validation of the affect
consciousness construct. J Pers Assess 2011;93:257–265.
27. SOLBAKKEN OA, HANSEN RS, MONSEN JT. Affect integration
and reflective function: clarification of central conceptual
issues. Psychother Res 2011;21:482–496.
28. ABBASS A. Intensive Short-Term Dynamic Psychotherapy for
treatment resistant depression: a pilot study. Depress Anxiety
2006;23:449–552.
29. JOHANSSON R, TOWN J, ABBASS A. Davanloo’s Intensive
Short-Term Dynamic Psychotherapy in a tertiary
psychotherapy service: overall effectiveness and
association between unlocking the unconscious and
outcome. PeerJ 2014;2:e548.
30. ABBASS A. Small-group videotape training for psychotherapy
skills development. Acad Psychiatry 2004;28:151–155.
31. ABBASS A, ARTHEY S, ELLIOTT J et al. Web-conference
supervision for advanced psychotherapy training: a
practical guide. Psychotherapy 2011;48:109–118.
32. YALOM ID. The Theory and Practice of Group
Psychotherapy, 5th edn. New York: Basic Books, 2005.
33. SHROUT PE, FLEISS JL. Intra-class correlations: uses in
assessing rater reliability. Psychol Bull 1979;86:420–466.
34. SINGER JD, WILLETT JB. Applied Longitudinal Data Analysis.
Modeling Change and Event Occurrence. New York: Oxford
University Press, 2003.
35. COHEN J. Statistical Power Analysis for the Behavioral
Sciences, 2nd edn. Hillsdale, NJ: Lawrence Erlbaum
Associates, 1988.
36. ADEDOKUN OA, BURGESS WD. Analysis of paired
dichotomous data: a gentle introduction to the McNemar
test in SPSS. J MultiDiscip Eval 2012;8:125–131.
37. MOREY LC, HOPWOOD CJ. Stability and change in personality
disorders. Annu Rev Clin Psychol 2013;9:499–528.
38. BOHART AC, WADE AG. The client in psychotherapy. In:
Lambert MJ, editor Bergin and Garfield’s Handbook of
Psychotherapy and Behavior Change, 6th edn. New York:
Wiley, 2013; p. 219–247.
39. TOWN JM, DIENER MJ, ABBASS A, LEICHSENRING F, DRIESSEN E,
RABUNG S. A meta-analysis of psychodynamic psychotherapy
outcomes: evaluating the effects of research-specific
procedures. Psychotherapy 2012;49:276–290.
Symptom- and personality disorder changes in residential ISTDP
15
