Analyst/Researcher Begins Landmark Trial

Although our field has produced many studies that can imply that psychodynamic psychotherapy is efficacious, the development of randomized, controlled trials (RCTs), carefully constructed according to rigorous and accepted scientific standards, has been challenging. Such studies are very costly to conduct, and obtaining funds for psychotherapy clinical trials requires an expertise in study design and a dedication to communicating with an academic community that insists on evidence-based treatments. Scientifically credible outcome research involves each of the following components: developing a manualized treatment that is truly psychodynamic; insuring adherence to the treatment; deciding upon an appropriate but less active comparison condition; choosing widely recognized, reliable, and valid outcome and follow-up measures; and devising appropriately sensitive data analytic procedures. All of these components are time consuming and require sophisticated training and ongoing consultation with experts in academic research. It is the vanishingly rare researcher who can manage to combine the development of such expertise with an ongoing commitment to practicing psychoanalysis.

Something of a force of nature, Barbara Milrod has dedicated her career toward accomplishing just this. An APsaA certified psychoanalyst who typically treats three or four patients in psychoanalysis at a time and an associate professor of psychiatry at Weill Medical College of Cornell University, she has developed a gold standard clinical trial that was published in the February 2007 American Journal of Psychiatry. The outcome study yields extraordinary results: For 49 patients with primary DSM IV panic disorder, a response rate of 73 percent for psychodynamic therapy, as compared with only 39 percent for applied relaxation training was documented, with a drop-out rate of only 7 percent in psychoanalytic psychotherapy as compared with 34 percent for relaxation training. Milrod and renowned psychotherapy researcher Jacques Barber have now teamed up to head an NIMH-funded two-center (University of Pennsylvania and Weill Medical College) RCT of psychodynamic psychotherapy versus cognitive behavior therapy versus applied relaxation training for 233 patients.

Milrod began the arduous journey toward this outcome when she and Columbia Psychoanalytic-trained Fredrick N. Busch, mentored by co-authors Arnold Cooper and Theodore Shapiro, wrote a manualized psychoanalytic treatment, the Manual of Panic-Focused Psychodynamic Psychotherapy, published by the American Psychiatric Press in 1997. This followed several years of Busch's work with M. Katherine Shear, a respected psychiatric researcher and panic disorder expert, studying common dynamics and defenses of patients who had panic disorder. When Milrod discussed the initial pilot study design with Jean Roiphe and me, former analytic classmates at NYPI, during our monthly poker game, we volunteered to participate in the initial group of study therapists, as did Andrew Aronson, another classmate, and Meriamne Singer, all graduate analysts. Study therapists have continued to be clinicians with at least three years of psychoanalytic training. The pilot open trial suggested that the treatment had a strong effect on patients' anxiety and accompanying depression, paving the way for Milrod to obtain a coveted Career Development K grant from the NIMH. The RCT that is now being published represents research from that project. In addition to the outcome research, pilot process studies have been developed as part of the RCT.

Milrod's choice of studying panic disorder patients was a calculated one. It is a disorder with considerable anecdotal data within the psychoanalytic field (including one of her own papers) suggesting that it is treatable by the analytic method, and it is one in which excellent research benchmarks from the non-psychoanalytic research world exist. Furthermore, there is room for improvement in response and remission rates in the treatments of panic disorder that have been previously studied. Milrod has also attempted to study a modified form of this treatment in adolescent panic patients, but it has not yet been possible to obtain funding for this project, despite the apparent need for such research in this population.

Milrod was told by an early analyst colleague that her research endeavor would “have a huge impact on the analytic field, but you will never receive a word of thanks for it by the institutes,” a comment on resistance within the psychoanalytic community to scientifically credible quantitative research. She does find her dual role as psychoanalyst and researcher to be a challenging one. Mainstream psychiatric researchers tend to be biased against psychodynamic therapies because of the paucity of rigorous research supporting them, while psychoanalytic institutes tend to view her work with some suspicion: “One colleague thought that I did psychopharmacologic research. Another senior analyst at my institute told me that he hoped that one day I would return to doing ‘real analytic treatment.’” However, her work is acclaimed by influential psychoanalysts such as colleague Glen Gabbard: “Barbara Milrod has blazed trails into terrain where few psychoanalysts have the courage to go. Her research is a landmark in the efforts of psychoanalysts to gain scientific credibility.”

Milrod gives considerable credit to her coauthors Busch, Shapiro, and Cooper for their extensive work on the early projects, as well as to Andrew Leon, professor of biostatistics at Weill, who has helped her enormously with learning details of study design, to her primary K grant mentor, John Clarkin, professor of clinical psychology in psychiatry at Weill, and to Shear and Abby Fyer, accomplished researchers in panic disorders for their generous mentoring. She is palpably excited about the two-center study, which represents the first time in which a psychodynamic treatment for anxiety disorders will be tested prospectively against cognitive behavioral therapy in such a large patient group.