Treatment-Resistant Depression and Anxiety

In clinical trials, somewhere between 20% and 50% of people who complete psychotherapy fail to achieve lasting benefits.[¹] Outside of clinical trials the failure rates are even higher. Depression that does not respond to multiple therapies or medications is known as Treatment Resistant Depression.

I specialize in Intensive Short-Term Dynamic Psychotherapy (ISTDP), one of the few methods proven effective for Treatment Resistant Depression. In a recent study of people with Treatment Resistant Depression, 84% of patients who had gotten little or no benefit in multiple prior treatments experienced either full (36%) or partial (48%) improvement.[²]
 
By contrast, only about 22% of patients who received “treatment as usual” (cognitive behavioral therapy or increase in medications) had total (3.7%) or partial (18.5%) remission.
 
No therapy will work for all people and all conditions. However, these findings show there is real hope for most people whose depression is longstanding and difficult to treat. Importantly, in the above study improvement came relatively quickly — in an average of 16 therapy sessions. 

Continued —

More on ISTDP for Treatment-Resistant Depression 

Why are some depressions more resistant to treatment than others? Resistance is usually related to personality factors, particularly how patients relate to others, such as the therapist.
 
Psychotherapy requires the patient to develop a working relationship of trust and engagement with the therapist. This relationship — the therapeutic alliance — is the bedrock of any successful therapy.

Patients bring to therapy many assumptions and tendencies — conscious and unconscious — about relationships that can affect the therapeutic alliance. ISTDP systematically addresses the many ways patients may resist forming a strong therapeutic alliance.
 
For example, people may approach therapy in a compliant or subservient way; or they may avoid emotional connection; or they might become fearful and anxious. Some become combative, seeing the therapist as a threat.
 
All of these approaches reflect how people have learned to adapt to past relationships, and can impede therapy. In ISTDP we address these relationship factors actively: Working through them is an essential part of the therapy. After all, the ways people create or limit relationships often contribute to depression in the first place.
 
The ISTDP therapist pays close attention to the body’s signals Working within an individual’s “window of tolerance” for anxiety is essential to a good therapy outcome. People whose anxiety is too high naturally withdraw, or may quit therapy altogether. If you are prone to higher levels of anxiety, we would probably spend more time practicing regulating your anxiety, particularly in the initial stages of therapy.
 
On the other hand, people who experience little anxiety often become discouraged in therapy because they feel “nothing is happening.” When we avoid anxiety in therapy — for example, by talking about issues without feeling an emotional connection — progress can grind to a halt. People who experience this may say, “We talked about a lot of things, and the therapist listened and made comments, but nothing changed.”

In ISTDP, we work together to develop a clear focus on your goals in each session, while closely monitoring your body’s experience of feelings and anxiety. This helps us stay in tune with what is emotionally important to you, to maximize the precious time you spend in therapy. The more focused we can stay on issues that have emotional value to you, the sooner you will see progress toward your goals.

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[¹] Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change  (169–208). Hoboken, NJ: Wiley.


[²] Town, J.M., Abbass, A., Stride, C., & Bernier, D. (2017). A randomized controlled trial of intensive short-term dynamic psychotherapy for treatment-resistant depression: The Halifax depression study. Journal of Affective Disorders, 214, 15–25.