Therapists' views on the challenges and helpful factors in long-term psychoanalytic therapy for treatment-resistant depression

Background: The Tavistock Adult Depression Study (TADS) demonstrated that long- term psychoanalytic therapy is more effective for Treatment-Resistant Depression (TRD) than treatment as usual, reporting that 30% of the patients reached partial remission. Aim: The aim of this study was to explore the experiences of the therapists, who provided TADS’ psychoanalytic therapies, and in particular, their views on the challenges and helpful factors to the therapeutic process and its outcome. Methods: Thematic analysis was used to analyse 23 Private Theories Interviews, which were conducted with therapists who treated patients that experienced partial remission after completing the 18-month treatment. Partial remission was defined as a Hamilton Depression Rating Scale score < 12. Secondary exploratory analysis compared the emerging themes between two groups of patients based on their outcome at the end of a 42-month follow-up: patients who sustained their remission (n = 11) and patients who did not (n = 12). Results: The analysis identified two main themes as helpful: ‘a containing and meaningful therapeutic relationship’ and ‘an effective psychoanalytic intervention’. Challenges were attributed to the effects of patients’ pathology on their views of the therapy and on their therapists. Only ‘insight gain’ was found to be identified differently depending on patients’ sustainment of remission. Conclusion: Establishing the therapeutic relationship through effective containment of patients over time was highlighted as a priority, as it enabled therapists to address patients’ pathology more directly. A multitude of pathological mechanisms and techniques were used, supporting the view of TRD as a broad category of depression. The effects of patients’ pathology interfered with the therapeutic efforts, and were mitigated by use of supervision and the support of others’ involved in the patients’ care. Further research is needed to understand the mechanisms of establishing patients’ sense of safety within the therapy and the effects of therapeutic changes on long-term outcome