Psychodynamic psychotherapy for personality disorders.

In 1990, Gerald Klerman argued persuasively, and surely noncontroversially, that psychiatric patients have a right to effective treatment (1). Klerman referred to litigation in which a patient hospitalized for 7 months at Chestnut Lodge held the hospital negligent for providing only intensive psychotherapy without adding antidepressant medication in spite of a marked worsening of his depressive condition. Klerman concluded that " the issue is not psychotherapy versus biological therapy but, rather, opinion versus evidence , " and he added that it is " regrettable that psychoanalysts and psychodynamic psychotherapists have not developed evidence in support of their claims for therapeutic efficacy " (p. 415). In 2007, Klerman's plea for the right to effective treatment is no less cogent, but his lament that " the efficacy of psychotherapies has not been addressed by NIH " (p. 414) no longer applies, at least to the treatment of depression. Since 1990, many clinical trials funded by the National Institutes of Health (NIH) have focused on psychotherapy as a treatment for depression, adding substantially to our menu of effective treatments for this disorder. But how are we doing developing an evidence base concerning the efficacy of psychotherapy, often longer term, for severe and disabling personality disorders that either stand alone or co-occur with depression or other axis I conditions? Here, Klerman's lament remains relevant, although we're making progress. Interest (long overdue) in rigorous random-ized, controlled trials of psychotherapy with this population has grown in the research community, and NIH funding for this work has increased. Leichsenring and Leibing (2) reported a meta-analysis of psychodynamic treatment and cognitive behavior therapy, concluding that both are effective treatments for personality disorders. However, only 14 psychodynamic studies and 11 cognitive behavior therapy studies (including dialec-tical behavior therapy) were found that used adequate methodology for inclusion; of these, three psychodynamic studies and five cognitive behavior therapy studies were randomized, controlled trials. The refrain that absence of proof does not equal proof of absence (of efficacy) is most often heard regarding psychodynamic psychotherapy. Fortunately, labor-intensive randomized, controlled trials of long-term psychodynamic treatment are being carried out, such as the work of Bateman and Fonagy (3) and the work of Clarkin and colleagues (4). However, numerous challenges remain. The number of subjects in each study is often small, intent-to-treat analyses are seldom reported, and head-to-head studies are rare. There is still much to learn about which treatment is best for which …