Efficacy of psychoanalysis and intensive psychoanalytic therapy for patients with substantial phobias, anxieties and panic states: a comment with new findings from the Menninger study
by Sherwood Waldron
One important result of the Menninger study of “42 Lives in Treatment”, as Wallerstein’s comprehensive 1986 report is called, is that substantial evidence has been gathered about the efficacy of psychoanalysis and intensive psychoanalytic psychotherapy. Over 80% of the patients benefitted, as judged by their status at 2 year follow-up. I have figured out a way to calculate the degree of benefit: there was an average improvement in quality-of-life in this group (the 80% who benefitted) of 37%, as measured by the best established measure of psychological quality-of-life, the Health-Sickness Rating Scale (originally described by Luborsky in 1962). The dramatic degree of benefit attained by the patients seen in psychoanalysis and long-term psychoanalytic psychotherapy over long periods of time has not been shown by lesser therapies, to my knowledge. The fact that this degree of benefit was present at an average of two years after termination contrasts with the findings of the Collaborative Multi-site study of Depression, in which only 25% of patients had substantially kept the benefits achieved at termination of their treatments. Recently, the American Psychiatric Association has released guidelines for the treatment of Panic Disorder which essentially do not acknowledge the role of intensive psychoanalytic therapies, including psychoanalysis in the treatment of panic conditions. I decided to examine the Menninger patient cohort to see if there were evidence bearing on the outcome of these intensive treatments for panic states. By way of introduction, I believe most clinicians would agree that the DSM designation of panic disorder, while useful for research purposes, should not be regarded as identifying a discrete group of patients, who are qualitatively different from patients whose anxieties and phobias from time to time threaten to verge on full-blown panic states. Without offering an extensive review of the literature, it is fair to assert that panic represents the extreme end of conditions affecting many patients. Wallerstein’s summary, which includes three- to five- page descriptions of all of the cases, does not specifically classify the cases as to the precise level of panic, although severe anxieties and phobias are mentioned throughout. Wallerstein summarizes the extent of these conditions: 37 of the 42 patients had central complaints of severe anxiety or depression, 23 with both anxiety and depression. For example, the Manic-depressive physician had anxiety all his life, including intense social anxieties through his adulthood. Involutional woman phobically anxious since childhood. Obedient Husband ever fearful his wife would no longer need him and therefore would no longer love him. The Actress reflected her pervasive distress in repetitive nightmarish dream and mood states. Tantrum Woman in constant anxiety over her impulses to kill her children. Patients who resisted or repressed these symptoms included the Fearful Loner, who successfully kept himself under rigid repressive controls, then when questioned about his symptoms assaulted the psychiatrist. In addition to the 23 with both anxiety and depression as major symptoms, there were another 9 with significant, very major anxiety (pp. 121-124, 150, passim). I re-examined the summaries of all the cases, and found nine with extensive phobias, and another nine with extensive anxieties and panic states. I made the same measurement of changes in Health-Sickness for these 18 patients in the spectrum of panic conditions, from initial evaluation to follow-up, as I did for the entire group of 42 patients. All of these 18 patients benefitted from treatment, showing an improvement in HSR from initial assessment, and the average percent increase in quality-of-life was 49%. This is an extraordinarily important finding. Not only does it provide substantial evidence of the effectiveness of psychoanalytic therapies for severe anxiety conditions, but it also provides a challenge to the cognitive-behavioral therapies to assess the degree of lasting benefit accruing from CBT. I do not mean to imply that cognitive-behavioral therapy has not been shown to be beneficial. My understanding is that it is a powerful therapeutic modality, and is of benefit to many people. However, these findings should provide a basis for correcting the [From Nov 30, 1997 e-mail to APSA] Some important facts: in the Menninger study of 42 lives (reported by Wallerstein, 1986), over 80% of the patients benefitted. I have figured out a way to calculate the degree of benefit: there was an average improvement in quality-of-life in this group of 37%, as measured by the best established measure of psychological quality-of-life, the Health-Sickness Rating Scale (originally described by Luborsky in 1962). The dramatic degree of benefit conferred on the patients seen in psychoanalysis and long-term psychoanalytic psychotherapy over long periods of time has not been shown by lesser therapies, to my knowledge. And this degree of benefit was what was present at an average of two years after termination. I originally calculated and published the degree of benefit in 1991 in JAPA, in the article reviewing Efficacy of Psychoanalysis with Henry Bachrach as first author. There is a table in that article which shows the distribution of change scores for the Menninger patients. However, it is only recently, as I have continued to write grant applications to support the process-outcome studies in analysis carried out by my group (known as the APS group for the Analytic Process Scales we have developed), that I realized these remarkable improvements in health-sickness could be expressed as a percent change in quality-of-life. This has the advantage of avoiding lengthy explanation about an average change of around 18 points on a 100 point scale of your mental health. Such an explanation tends to lose many listeners, unfortunately. I hope this information will be useful to those among us who have opportunities to speak or write supporting psychoanalysis or rebutting those who persistently claim there is no solid evidence about the efficacy of psychoanalysis and intensive psychoanalytic psychotherapy. A more complete article is in preparation, with references, entitled “The Tail Wags the Dog: Panic Disorder Reconsidered, which will be posted here when complete.