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Psychiatry Research 208 (2013) 162173

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Psychological predictors of the recovery from mood or anxiety disorder in


short-term and long-term psychotherapy during a 3-year follow-up
Maarit A Laaksonen a, Paul Knekt a,b,c,n, Olavi Lindfors a
a

National Institute for Health and Welfare (THL), Department of Health, Functional Capacity and Welfare, Helsinki, Finland
Biomedicum Helsinki, Helsinki, Finland
c
Social Insurance Institution, Helsinki, Finland
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 18 August 2011
Received in revised form
13 August 2012
Accepted 27 September 2012

Choice of optimal treatment length for psychiatric patients requires knowledge about the patients
pre-treatment suitability. This study compares the prediction of seven psychological suitability
measures on changes in psychiatric symptoms in short- and long-term psychotherapy over a 3-year
follow-up. The psychological suitability of 326 outpatients from the Helsinki Psychotherapy Study, aged
2046 years, and suffering from mood or anxiety disorders, was assessed at baseline using the
Suitability for Psychotherapy Scale (SPS) before randomly assigning them to solution-focused therapy,
short-term or long-term psychodynamic psychotherapy. Psychiatric symptoms (Symptom Checklist-90
Global Severity Index) were assessed at baseline and seven times during follow-up. Three patient
groups with different prognosis were found when a cumulative SPS score, summing up the values of the
seven single suitability measures, was used to predict symptom development: patients with more good
(4 or more) than poor values beneted more from short-term therapy, patients with more poor (46)
than good values beneted more from long-term therapy, and patients with all seven values poor failed
to benet from either short- or long-term therapy. The SPS can apparently be applied before the start of
treatment to predict the amount of therapy patients need to recover, although its suitability in
therapies of different types needs to be conrmed.
& 2012 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Psychological suitability
Psychiatric symptoms
Depression
Treatment
Psychodynamic
Solution-focused

1. Introduction
As the need for treatment of mental health disorders continues
to rise and health care resources become more limited, the
demand for methods that allow us to choose effective treatment
for each psychiatric patient grows. If the treatment chosen is
unsuitable for the patients, no change or even a change for the
worse in their symptoms may occur, thus causing unnecessary
suffering and treatment costs. Evidence-based information can
help in choosing a suitable treatment for a patient with psychiatric symptoms. Although theoretical arguments on patient suitability have been reported from early on (Sifneos, 1972; Malan,
1976), the assessment of suitability remains unsatisfactory
(Laaksonen et al., 2012), and empirical studies on the prediction
of pre-treatment suitability on psychotherapy outcome, especially in
long-term therapies, are scarce (Valbak, 2004). The effectiveness of
short- and long-term psychotherapy on psychiatric symptoms in
the treatment of patients suffering from mood and anxiety
disorders has been predicted using factors related to the therapy

n
Corresponding author at: National Institute for Health and Welfare (THL),
Department of Health, Functional Capacity and Welfare, P.O. Box 30,00271,
Helsinki, Finland. Tel.: 358 29 524 8774; fax: 358 29 524 8760.
E-mail address: paul.knekt@thl. (P. Knekt).

0165-1781/$ - see front matter & 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2012.09.053

(i.e., form and length of therapy (Churchill et al., 2001; Knekt


et al., 20081) and alliance (Martin et al., 2000)), therapist (i.e.,
education, clinical experience, and personality (Beutler et al.,
2004; Heinonen et al., 20121)) and patient (i.e. socio-economic
factors (Frank et al., 2002), psychiatric symptoms, diagnosis, and
psychiatric history (Driessen et al., 2010, Carter et al., 2011),
social factors (Marttunen et al., 20081) and personality (Valbak,
2004)), but the knowledge is still fragmentary. Altogether more
than 200 patient factors have been proposed as potentially
important in matching patient and therapy (Norcross and
Wampold, 2011). Recent practice guidelines have, based on
knowledge from meta-analyses and expert panels on factors
affecting psychotherapy effectiveness, recommended that certain
patient characteristics, such as stages of change (Norcross et al.,
2011), resistance/reactivity (Beutler et al., 2011a), and coping
style (Beutler et al., 2011b), should be acknowledged in adapting
psychotherapy for a specic person (Norcross and Wampold,
2011). These are all related to the patients personality characteristics
and interpersonal predispositions, which have not been covered by
research sufciently, although they are considered important when

1
These studies are based on the same data as the one used in the
present study.

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

evaluating a patients general suitability for psychotherapies of


different types (Malan, 1976) and lengths (American Psychiatric
Association, 1985; Blenkiron, 1999) and ability to create a functioning alliance with the therapist. Such psychological suitability factors
have traditionally been conceptualized along the dimensions of ego
resources and motivation (Sifneos, 1972), indicating patient characteristics which facilitate participation in psychotherapy and help to
maintain alliance and task-orientation (Valbak, 2004), which are
relevant in all kinds of psychotherapies. These characteristics can be
categorized comprehensively, based on the psychodynamic tradition
and terminology, into four domains ego strength, self-observing
capacity, nature of problems, and intrapsychic and interpersonal
behavior. These domains cover major elements of suitability also
acknowledged in other than the psychodynamic orientation, such as
the capacity for dealing with affects, potential for establishing
alliance, dysfunctional characterological traits, focality of problems,
and sufcient motivation for the therapeutic endeavor, as indicated
by suitability scales in cognitive and interpersonally focused therapies (Safran et al., 1993; Myhr et al., 2007). It has been suggested that
psychological suitability factors may serve either as indications or
contraindications for suitability for psychotherapy: for patients with
healthy aspects of personality, and accordingly good values of
suitability factors, short-term therapy may be more benecial,
whereas for patients with less-developed aspects of personality,
and poorer values of suitability factors, long-term therapy, which
aims at structural changes in personality, is likely to be more
benecial (Hoglend, 1993; Van et al., 2009). Therefore, these aspects
of psychological suitability could potentially be used in the selection
of patients for short- and long-term therapy. The prediction of such
suitability factors has been considered in several studies on different
types of short-term therapies (McBride et al., 2006; Joyce et al.,
2007; Marshall et al., 2008; Laaksonen et al. 2012), but relatively
few differences in the prediction of different suitability factors
between different short-term therapies have been found. For longterm therapies, the prediction of suitability factors has only been
explored in few cohort studies (Valbak, 2004). Most importantly, no
randomized clinical trials comparing the prediction of suitability
factors in short- and long-term therapy have been carried out to
date. Thus, it is unknown whether the suitability factors predicting
the effectiveness of short-term therapy also predict effectiveness of
long-term therapy and whether the prediction differs depending on
the values (good versus poor) of the suitability factors (Malan, 1976;
Wilczek et al., 2004). Furthermore, even the studies on short-term
therapies have mainly concentrated on only one or two suitability
factors at a time, whereas studies in which the potential simultaneous or cumulative effect of several different suitability factors
have been studied are scarce (Brodaty et al., 1982; Piper et al., 1985;
Cromer and Hilsenroth, 2010). Also studies in which suitability
factors are assessed in relation to other patient variables (Buckley
et al., 1984; Lorentzen and Hoglend, 2004), or to the therapy process
(Klein et al., 2003), are scarce. Therefore, knowledge of the mutual
effect of different suitability factors and of their relative importance
in comparison with other predictive factors is incomplete.
In this study, we examine and compare in a randomized
clinical trial the prediction of seven suitability factors modulation of affects, exibility of interaction, and self-concept in
relation to ego ideal (representing ego strength), reective
ability, trial interpretation, and motivation (representing selfobserving-capacity), and focus (representing nature of problems)
alone and combined, on outcome of short- and long-term
therapy during a 3-year follow-up. We hypothesized that
patients with poor suitability, demonstrated by an overall poor
suitability score, as well as specically by lesser ego strength,
restricted self-observing capacity and absence of focal problems,
would benet more from long-term than short-term psychotherapy, especially in the long run, while better suitability would

163

predict faster improvement in and sufciency of short-term


therapy.

2. Methods
This study was part of the Helsinki Psychotherapy Study. The methods used
have been described in detail elsewhere (Knekt and Lindfors, 2004; Knekt et al.,
2008) and are summarized briey here. Patients gave written informed consent.
The study protocol was approved by the Helsinki University Central Hospitals
ethics council.

2.1. Patients
Outpatients from the Helsinki area were referred to the study by local
practitioners from 1994 to 2000 (Knekt and Lindfors, 2004; Knekt et al., 2008).
Eligible patients were 2045 years of age and had a long-standing ( 4 1 year)
disorder causing work dysfunction. They had to meet DSM-IV criteria (American
Psychiatric Association, 1994) for anxiety or mood disorders evaluated based on a
semi-structured diagnostic interview (Knekt and Lindfors, 2004) and criteria for
neurosis to higher-level borderline personality organization evaluated based on a
psychodynamic assessment interview (Kernberg, 1996). The patients were
excluded if they had a psychotic disorder or severe personality disorder (DSMIV cluster A personality disorder and/or lower level borderline personality
organization), bipolar I disorder, adjustment disorder, or substance-related disorder, or if they had been in psychotherapy during the previous 2 years.
Psychiatric health employees were also excluded.
Altogether 459 patients were considered eligible (Fig. 1), but 133 of them
refused to participate. The remaining 326 patients were randomized to solutionfocused therapy (N 97), short-term psychodynamic psychotherapy (N 101) or
long-term psychodynamic psychotherapy (N 128). As no notable differences in
the prediction of the suitability factors on outcome of solution-focused therapy
and short-term psychodynamic psychotherapy were found during the 3-year
follow-up (Laaksonen et al., 2013), these were combined into one short-term
therapy group (N 198). Of the patients randomized, 33 refused to participate, and
42 of those starting the treatment discontinued prematurely. The average number
of therapy sessions among patients starting short-term therapy was 14.3
(S.D. 5.5) and among those starting long-term psychotherapy 232 (S.D. 105).

2.2. Therapies and therapists


The patients were monitored for 3 years after randomization. During the
follow-up, patients were provided with either short-term therapy, followed by no
treatment, or long-term therapy (Knekt and Lindfors, 2004; Knekt et al., 2008).

2.2.1. The therapies


Solution-focused therapy (SFT) is a brief resource-oriented and goal-focused
therapeutic approach, helping clients change by constructing solutions (Johnson
and Miller, 1994; Lambert et al., 1998). The orientation was based on an approach
developed by de Shazer et al. (1986) and de Shazer (1991). The frequency of
sessions was exible, usually one every second or third week, with a maximum of
12 sessions over no more than 8 months.
Short-term psychodynamic psychotherapy (STPP) is a brief, focal,
transference-based therapeutic approach, helping patients by exploring and
working through specic intrapsychic and interpersonal conicts. The orientation
was based on approaches described by Malan (1976) and Sifneos (1978). The
therapy was scheduled for 20 treatment sessions, one session a week, over 56
months.
Long-term psychodynamic psychotherapy (LTPP) is an open-ended, intensive,
transference-based therapeutic approach, helping patients by exploring and
working through a broad area of intrapsychic and interpersonal conicts. Therapy
includes both expressive and supportive elements, the use of which depends on
patient needs. The orientation followed the clinical principles of long-term
psychodynamic psychotherapy (Gabbard, 2004). The frequency of sessions was
23 sessions a week and the duration of therapy up to 3 years.

2.2.2. The therapists


Altogether 55 therapists participated in the study; six provided SFT, 12 STPP,
and 41 provided LTPP (Knekt et al., 2008). All the therapists had been trained in
the respective therapy form. The mean number of years of experience in the
therapy form provided was 9 (range 315) in SFT, 9 (range 220) in STPP, and 18
(range 630) in LTPP. Additionally, the therapists providing STPP had a mean of 16
years (range 1021) experience in LTPP, while none of the therapists providing
SFT had received any training in psychodynamic psychotherapy and vice versa.
Only SFT was manualized, and a centralized clinical adherence monitoring of
supervised cases was performed. Both psychodynamic psychotherapies were

164

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

459 Assessed eligible

133 Refused to participate

326 Randomly assigned to treatment

198 Short-term therapy


7 Did not start treatment
21 Discontinued treatment
170 Finished allocated treatment

128 Long-term therapy


26 Did not start treatment
21 Discontinued treatment
78 Finished allocated treatment
3 Treatment ongoing

Participation in measurements
180 1-year
154 2-year
159 3-year

Participation in measurements
115 1-year
102 2-year
107 3-year

Fig. 1. Number of eligible patients who were assigned to study group and completed the protocol.

conducted in accordance with clinical practice, where interventions can be


modied to patients needs within the psychodynamic framework.
2.3. Assessments at baseline
Assessment of suitability for psychotherapy was carried out based on interview
and assessment of potential confounding factors of the relationship between suitability
measures and psychotherapy outcome, based on interviews and self-report questionnaires. All these assessments were carried out at baseline before randomization to the
therapies. The interviews were carried out using a semi-structured procedure (Knekt
and Lindfors, 2004; Laaksonen et al., 2012), a modication of Kernbergs Structural
Interview (Kernberg, 1981), conducted in altogether three sessions, by experienced
clinical raters, who were not involved in patients assignments or treatment.
2.3.1. Suitability measures
The assessment of the suitability for psychotherapy was carried out using a 7item Suitability for Psychotherapy Scale (SPS), (Laaksonen et al., 2012). This scale
has similarities to other suitability scales generally used in short-term psychodynamic therapies (Malan, 1976) and psychoanalysis (Bacharach and Leaff, 1978), ,
but it was extended to be applicable in all forms of therapy provided in the current
study. The seven suitability measures were divided into three domains ego
strength, self-observing capacity, and nature of problems according to their
clinically relevant conceptual scope (Appendix 1). The ego strength domain
included measures representing psychological capacities related to dealing with
affects, interpersonal relations and self-structure, all being derivatives of the
global psychodynamic concept of ego strength and thus expressing different
aspects of the capacity to deal adaptively with internal and external demands and
reality (Kernberg et al., 1972; Lake, 1985). The self-observing capacity domain
consisted of measures related to an orientation towards therapy and capacities for
the process, including reective ability, reaction to trial interpretation and
motivation for addressing problems psychologically, extending and integrating
elements of psychological-mindedness and motivation for change (Piper et al.,
1998; Appelbaum, 1972). The nature of problems domain consisted of a measure
of the focality of the problems (Malan, 1976; Sifneos, 1979).
Each of the seven suitability measures was assessed independently on a 7point scale, where low and intermediate values were considered good and high
values poor, except for motivation and focus, for which both intermediate and
high values were considered poor (Appendix 1, Laaksonen et al., 2012). These
seven measures were thus standardized and made comparable by dichotomizing
them. A cumulative SPS score was formed by summing up the values of the seven

single dichotomous suitability variables (good values 0 and poor values 1) so


that the score varied from 0 to 7. The cumulative score was further analyzed as
low (03), intermediate (46) or high (7), where low values were considered good
(patient had more good than poor values in the single suitability measures) and
intermediate and high values poor (patient had more poor than good values).
The reliability of the SPS assessments, both the original seven-category and
dichotomized assessments, made by seven individual raters was evaluated
thoroughly by measuring both the repeatability of individual raters assessments
over time and agreement between individual raters assessments and a reference
assessment (Laaksonen et al., 2012). The median kappa coefcients of 3-year
repeatability within raters and of agreement between raters and a reference
assessment of the dichotomized suitability variables varied from 0.41 to 0.84 and
from 0.43 to 0.83 (motivation (0.41, 0.43), self-concept in relation to ego ideal
(0.41, 0.53), modulation of affects (0.44, 0.53), reective ability (0.51, 0.62), trial
interpretation (0.52, 0.50), exibility of interaction (0.84, 0.83), respectively), with
the exception of focus (0.23 and 0.00, respectively), showing fair to good
agreement beyond chance. The median kappa coefcients for the SPS score were
0.52 and 0.69, respectively.

2.3.2. Potential confounding factors


Psychiatric diagnoses at axes I and II were assessed based on the interview
according to the DSM-IV diagnostic criteria (American Psychiatric Association,
1994). Also two of the symptom measures, the 17-item Hamilton Depression
Rating Scale (HDRS) (Hamilton, 1960) and the 14-item Hamilton Anxiety Rating
Scale (HARS) (Hamilton, 1959), were assessed based on the interview. Other
potential confounding factors, including other symptom measures (the 21-item
Beck Depression Inventory (BDI) (Beck et al., 1961) and the 10-item Symptom
Check List, Anxiety scale (SCL-90-Anx) (Derogatis et al., 1973)), sociodemographic
factors (sex, age, marital status, and education), psychiatric history (age at the
onset of primary psychiatric disorder, separation experiences at childhood), and
previous psychiatric treatment (psychotropic medication and psychotherapy),
were assessed using questionnaires.

2.4. Assessments at follow-up


At baseline and during follow-ups at 3, 7, 9, 12, 18, 24 and 36 months after
baseline examination, the Symptom Check List, Global Severity Index (SCL-90-GSI)
(Derogatis et al., 1973), measuring general psychiatric symptoms, served as the
out-come measure.

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

2.5. Statistical methods


The statistical analyses were based on linear mixed models (Verbeke and
Molenberghs, 1997) carried out using SAS software, version 9.1 (SAS Institute Inc.,
2007). The main analyses were based on the intention-to-treat (ITT) design.
anen

Complementary as-treated (AT) analyses were also performed (Hark


et al.,
2005; Knekt et al., 2008). The primary analyses were based on the assumption of
ignorable dropouts (Knekt et al., 2008). In secondary analyses, missing values were
replaced by Multiple imputation. The imputation was based on Markov chain
Monte Carlo methods. Model-adjusted outcome means and mean differences were
calculated for different measurement points (Lee, 1981). The delta method was
used for the calculation of condence intervals (Migon and Gamerman, 1999).
Statistical signicance was tested with the Wald test.
The SCL-90-GSI was used as the dependent variable in all analyses. The basic
ITT model included as independent variables the suitability measure of interest
(one of the seven single dichotomous suitability measures of SPS or the cumulative SPS score representing overall suitability) measured at baseline, therapy
group (short-term versus long-term), and time (i.e., follow-up measurement
points), their rst- and second-order interactions, a correction term (i.e. the
rst-order interaction of the difference between theoretical and realized date of
measurement, time and the suitability measure), and SCL-90-GSI at baseline. The
independent variable of main interest was the interaction term between the
particular suitability measure considered, the therapy group, and time, telling us
whether the association between the baseline level of that suitability measure and
symptoms at follow-up differed between the short- and long-term therapy and
how. The complete ITT model was further adjusted for the confounding variables
age, sex, marital status, education, age at onset of the rst psychiatric disorder,
separation experiences at childhood, DSM-IV diagnoses (axes I and II, and comorbidity), psychiatric symptoms (HDRS, HARS, BDI, SCL-90-Anx), and earlier use
of psychotherapy or psychotropic medication, all measured at baseline and
satisfying the criteria for confounding (Rothman and Greenland, 1998). The AT
model was created by adding variables describing waiting time from randomization to initiation of treatment and degree of participation (i.e., withdrawal from or
discontinuing of treatment) during follow-up as main effects to the complete ITT
model, to further adjust for compliance. All three models (ITT basic, ITT complete,
AT) were carried out based on both the original data and imputed data. Imputation
attenuated the results obtained based on the original data, but the conclusions
were not changed as the statistical signicance of the ndings remained (data not
shown). Since no major differences were found between the different models and
imputation did not noticeably alter the results, those presented are based on the
basic ITT model as based on the original data.
We evaluated the signicance of the suitability measure of interest in
predicting the outcome of short-term versus long-term therapy during the 3year follow-up by testing the statistical signicance of the interaction term
between the suitability measure and the therapy group throughout the followup. The Wald test was used.
We assessed statistical signicance of the change in outcome from the
3-month follow-up point (due to adjustment for baseline symptom level) to the
different measurement points for each therapy group (short-term and long-term)
and category (good and poor) of suitability measure considered. Therapy was
considered benecial for the patients who experienced and maintained a statistically signicant reduction in symptoms in comparison with the 3-month followup point during the 3-year follow-up.
We measured the statistical signicance of the model-adjusted difference in
the outcome between the therapy groups in categories of the suitability measure
at the different measurement points. We considered short-term therapy to be
equally or more benecial than long-term therapy for the patients for whom there
were no statistically signicant differences between the therapy groups or who
beneted more from short-term therapy whereas long-term therapy was considered to be more benecial for patients who in the long run beneted more from
long-term therapy.

3. Results
3.1. Description of the study population
The study sample consisted of 326 patients, ranging in age
from 20 to 46 years (mean 32 years), with approximately 25%
male subjects (Table 1). Approximately one in four of the patients
had completed university education. A total of 85% of the patients
suffered from mood disorder, 44% had anxiety disorder, and
personality disorders were diagnosed in 18%. About one in ve
of the patients had used psychotropic medication or had received
psychotherapy previously. According to the cumulative SPS score,
almost 80% of the patients had good overall suitability. No notable

165

differences were found between short-term and long-term therapy groups in the variables considered, with the exception of a
higher prevalence of anxiety disorder, co-morbid anxiety and
mood disorder and personality disorder in the short-term therapy
group.
3.2. Description of the suitability measures
The correlation matrix revealed both strong intra- and intercorrelations for different domains of suitability measures
(Table 2). In the ego strength domain, strong correlation was
found between modulation of affects and exibility of interaction
(r 0.45). The measures of the self-observing capacity domain,
however, correlated more strongly with these ego strength
measures (r 0.140.46) than with each other (r 0.040.30).
Focus did not noticeably correlate with any of the other suitability
measures (r 0.080.20) or with the cumulative SPS score
(r 0.24). The score, however, correlated highly with its
other components (r 0.330.73). There were no statistically
signicant correlations between the single suitability measures
or the score and the outcome measure, SCL-90-GSI, at baseline
(r  0.060.10).
3.3. Prediction of suitability measures
Prognoses for therapy outcome were determined for patients
assessed with good and poor values in seven single suitability
measures and a cumulative SPS score summing up the values of
all seven items.

3.3.1. Single suitability factors


There was one statistically signicant and one suggestive
interaction between the suitability measures and the therapy
group (Table 3). Patients with a clearly circumscribed focus
experienced a statistically signicantly greater symptom reduction in long-term therapy (60% versus 38% reduction in long-term
versus short-term therapy at the 3-year follow-up point), whereas
the symptoms of patients whose focus was difcult to determine
were reduced equally much over time in both short-term and
long-term therapy (p-value for global test of interaction0.05).
On the other hand, patients who responded well to trial interpretation beneted more quickly from short-term therapy,
whereas patients whose response to trial interpretation was poor
beneted statistically signicantly more from long-term therapy
(43% versus 19% symptom reduction in long-term versus shortterm therapy at the 3-year follow-up point) (p-value for global
test of interaction0.08). Some consistent differences in symptom development between short-term and long-term therapies at
different points of the follow-up were also found in relation to the
suitability measures for which no statistically signicant interaction with the therapy group was found. For patients with good
values in the suitability measures, these differences were on the
benet of short-term therapy which resulted in a faster symptom
reduction than long-term therapy during the rst year of followup. Long-term therapy did not outperform short-term therapy
even in the long run, except for patients with good reective
ability whose symptoms reduced statistically signicantly more
in long-term therapy (49% versus 38% reduction in long-term
versus short-term therapy at the 3-year follow-up point). For
patients with poor values in suitability measures, on the other
hand, the differences were on the benet of long-term therapy.
The symptom reduction was statistically signicant only in longterm therapy, except for patients with poor motivation who also
beneted statistically signicantly from short-term therapy.

166

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

Overall, according to our criteria, good values in ve of the


seven suitability measures indicated that short-term therapy was
likely to be equally or more benecial than long-term therapy
while poor values showed that long-term therapy was likely to be
more benecial than short-term therapy in the long run. For
patients with good values in the suitability measures, the symptom reduction in short-term therapy over the 3-year follow-up
was much greater (3741%) than for patients with poor values in
these measures (932%). In long-term therapy, on the other hand,
both patients with good and poor values in suitability measures
experienced a substantial symptom reduction over the 3-year
follow-up (4760% versus 3145% reduction for those with good
versus poor values).

3.3.2. The SPS score


The cumulative SPS score, formed by summing up the values
of the seven single suitability measures, was found to differentiate between the outcome of short-term and long-term
psychotherapy during the 3-year follow-up (Table 4, Fig. 2).
In short-term therapy, only those patients who were assessed
as having more good than poor values (score values 03)
experienced and maintained a statistically signicant symptom
reduction, which was faster than in long-term therapy

(Table 4). Their range of SCL-90-GSI was 0.670.84 at the 3year follow-up point with an average symptom reduction of
38% in contrast to SCL-90-GSI 0.95-1.16 with an average
symptom reduction of 19% for those assessed as having mostly
poor values (score values 46), and SCL-90-GSI 1.49 with an
average symptom increase of 18% for those with all seven
values poor. In long-term therapy, although not statistically
signicantly better than short-term therapy, both patients
assessed as having more good than poor values (score values
03) and patients assessed as having mostly poor values (score
values 46) experienced a statistically signicant symptom
reduction. The ranges of SCL-90-GSI at the 3-year follow-up
point were 0.610.78 and 0.610.84 with average symptom
reductions of 49% and 38% for those with score values of 03
and 46, respectively. Only those patients for whom all seven
values were poor remained at a high symptom level (SCL-90GSI 1.27). Accordingly, for patients who were assessed as
having mostly good values in the suitability measures, shortterm therapy seemed more benecial due to its faster effect,
whereas patients who were assessed as having mostly poor
values seemed to benet more from long-term therapy in the
long run, and patients for whom all values were poor did not
seem to benet from either short-term or long-term therapy
(Fig. 2).

Table 1
Baseline characteristics of patients intended to treat.
Predictor

Demographic variables
Men (%)
Age (years)d
University degree (%)
Living alone (%)
Diagnoses
Mood disorder (%)e
Anxiety disorder (%)f
Co-morbid mood and anxiety disorder (%)
Personality disorder (%)g
Symptoms
Symptom Check List, Global Severity Index (SCL-90-GSI)d
Beck Depression Inventory (BDI)d
Symptom Check List, Anxiety scale (SCL-90-Anx)d
Psychiatric history
Previous psychotherapy (%)h
Previous medication (%)i
Separation experiences at childhood (%)j
Suitability for psychotherapy
Ego strength
Modulation of affects (%)k
Flexibility of interaction (%)k
Self-concept in relation to ego ideal (%)k
Self-observing capacity
Reective ability (%)k
Trial interpretation (%)k
Motivation (%)k
Nature of problems
Focus (%)k
Suitability for Psychotherapy Scale (SPS) score (%)l
a

P-valuec

Group
Shorta (N 198)

Longb (N 128)

25.8
32.8 (7.1)
24.2
52.5

21.1
31.6 (6.6)
28.1
49.2

0.34
0.11
0.44
0.56

82.3
48.0
47.0
21.7

88.3
36.7
36.7
12.5

0.15
0.05
0.07
0.03

1.3 (0.5)
18.0 (7.6)
1.3 (0.7)

1.3 (0.6)
18.8 (8.3)
1.2 (0.7)

0.80
0.38
0.37

19.4
24.7
48.0

19.0
17.6
51.8

0.94
0.13
0.62

65.7
87.9
80.8

71.9
90.6
85.2

0.24
0.44
0.31

80.8
69.2
38.9

82.8
64.8
39.1

0.65
0.41
0.98

36.5
78.2

36.7
79.7

0.98
0.75

Short-term therapy group: short-term psychodynamic psychotherapy and solution-focused therapy combined.
Long-term therapy group: long-term psychodynamic psychotherapy.
Test for differences between short- and long-term therapy groups.
d
Mean (SD).
e
Proportion of patients with mood disorder only or co-morbid mood and anxiety disorder.
f
Proportion of patients with anxiety disorder only or co-morbid mood and anxiety disorder.
g
Proportion of patients with main diagnoses on Axis II (personality disorder).
h
Proportion of patients who have had previous psychotherapy.
i
Proportion of patients who have used psychotropic medication.
j
Proportion of patients with signicant separation experiences at childhood.
k
Proportion of patients with good values of the suitability measure. See Appendix 1 for classication of the measures.
l
Proportion of patients with good suitability score (values 03).
b
c

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

4. Discussion
4.1. Main ndings
This study is, as far as we know, the rst to compare the
prediction of psychological suitability based on psychiatric symptoms in short- and long-term therapy. The Suitability for Psychotherapy Scale (SPS), with both its seven single measures and
the cumulative score, was used as a measure of suitability
(Laaksonen et al., 2012). Five of seven suitability measures
predicted that patients assessed with mainly good values in them
would benet faster from short-term therapy and indicated that
patients assessed with mainly poor values may benet more from
long-term therapy in the long run. According to the score,
patients with all seven values assessed as poor would likely fail
to gain at all from the therapies studied.
The SPS consists of seven suitability measures modulation of
affects, exibility of interaction, self-concept in relation to ego
ideal, reective ability, trial interpretation, motivation, and focus
hypothesized to be relevant for suitability for both short- and
long-term therapies, either as indications or contraindications
(Malan, 1976; American Psychiatric Association, 1985; Blenkiron,
1999). The present study showed that the prediction of these
seven measures differed in short- and long-term therapy. Good
values seemed to serve as indications for potentially faster
recovery in short-term therapy than in long-term therapy, and
poor values potentially as contraindications to short-term therapy, but not to long-term therapy. This study thus empirically
conrmed the theoretical arguments about the importance of
taking indicators of the patients psychological capacity into
account when choosing between treatments with short- or
long-term therapy. The fact that some patients did not seem to
benet from short-term therapy, and some not even from longterm therapy, showed that the selection of treatment length
based on these suitability criteria leads to a different treatment
choice than pure randomization.
The prediction of variables from all four suitability domains
ego strength, self-observing capacity, nature of problems, and
intrapsychic and interpersonal behavior on psychiatric symptoms has been studied in the past for short-term therapies
(Valbak, 2004). Although most of these studies have focused on
the intrapsychic and interpersonal behavior of the patients, ego
strength and self-observing capacity in particular have been
found to predict psychiatric symptoms (Laaksonen et al., unpublished results). In long-term therapy, only the effect of interpersonal relationships on psychiatric symptoms has been explored

167

(Jorgensen et al., 2000), and nothing is thus known of the


prediction of ego strength, self-observing capacity, or the nature
of problems. The SPS focuses on these three domains less covered
in the literature.
In the present study, good values in all three variables related
to ego strength modulation of affects, exibility of interaction
and self-concept in relation to ego ideal were found to predict
faster reduction in symptoms in short- than in long-term therapy,
whereas poor values predicted a statistically signicant symptom
reduction in long-term therapy only. These variables thus differentiated the outcome between short- and long-term therapies
well. This nding is in accordance with the suggestion that
both adequate modulation of affects and exibility of interaction
are important for successful short-term therapy, as reported in
some (Brodaty et al., 1982; Husby, 1985; Husby et al., 1985;
Ogrodniczuk et al., 2004) but not all (Simons et al., 1985; Hoglend,
1993; Sigal et al., 1999) studies published. The only previous
study on the role of self-concept in short-term therapy (Horowitz
et al., 1984) was, however, at variance with our nding, and thus
more research is needed.
In the domain of self-observing capacity, the reaction to trial
interpretation was found to behave similarly to the variables in the
ego strength domain. As this is apparently the rst study assessing
the prediction of trial interpretation, this nding also has to be
veried in future studies. In the literature, good reective ability and
motivation, the two other variables, have been found relevant for
success in short-term therapy (Valbak, 2004). In this study, patients
with good reective ability experienced a statistically signicantly
faster symptom reduction in short-term therapy, but in the long run
the symptom reduction was statistically signicantly greater in longterm therapy. Patients with poor reective ability experienced a
statistically signicant symptom reduction only in long-term therapy. Motivation, whether good or poor, on the other hand did not
differentiate between the outcomes in short- and long-term therapy.
Although a clearly circumscribed focus has been considered
very important in short-term therapies (Balint et al., 1972;
Friedman and Lister, 1987; Perry et al., 1987), none of the studies
published on focus found any signicant prediction on psychiatric
symptoms in short-term therapy (Husby, 1985; Husby et al.,
1985; Hoglend, 1993; Hoglend and Heyerdahl, 1994; Sigal et al.,
1999). In this study, clearly circumscribed focus appeared to be
important for success in long-term therapy, whereas patients
without clearly dened focus beneted as much from short- as
from long-term therapy. The theoretical suggestions and empirical ndings on focus thus seem to remain contradictory, and more
research is needed on this topic.

Table 2
Correlation matrix for the dichotomous suitability measures.
Suitability measures
Ego strength
Modulation of affects (1)
Flexibility of interaction (2)
Self-concept in relation to ego ideal (3)
Self-observing capacity
Reective ability (4)
Trial interpretation (5)
Motivation (6)
Nature of problems
Focus (7)
Suitability for Psychotherapy Scale score (8)
OUTCOME VARIABLE
Symptom Check List, Global Severity Index
(SCL-90-GSI) (9)
a
b
c

p-value o0.05.
p-value o 0.01.
p-value o 0.001.

1.000
0.45c
0.15b

1.000
0.20c

1.000

0.46
0.27c
0.21c

0.44
0.36c
0.14a

0.30c
0.13a
0.10

1.000
0.28c
0.30c

1.000
0.04

1.000

0.16b
0.60c

0.13a
0.60c

0.08
0.37c

0.18b
0.73c

0.19c
0.50c

0.20c
0.33c

1.000
0.24c

1.000

0.02

 0.04

0.10a

0.02

 0.03

 0.02

 0.06

0.02

1.000

168
Table 3
Mean values of SCL-90-GSI in short-term and long-term therapy and mean value differences (95% condence intervals) between short-term and long-term therapy at 3-, 7-, 12-, 24- and 36-month follow-up according to the
good and poor values of the seven individual suitability measures.
Measure

Ego strength
Modulation of affects

Self-concept in relation to ego ideal

Self-observing capacity
Reective ability

Trial interpretation

Motivation

Nature of problems
Focus

Gooda

Poorb

12

24

36

Short
Long
S-Lc

1.02
1.08

Short
Long
S-Lc

1.02
1.09

Short
Long
S-Lc

0.97
1.03

0.88
1.05
 0.17*
(  0.31,  0.03)
0.88
1.04
 0.17n
(  0.29,  0.04)
0.88
1.03
 0.15n
(  0.28,  0.02)

0.82
0.94
 0.12
(  0.26, 0.02)
0.79
0.95
 0.15n
(  0.27,  0.04)
0.80
0.94
 0.14n
(  0.26,  0.01)

0.85
0.81
0.04
(  0.12, 0.20)
0.85
0.82
0.03
(  0.11, 0.17)
0.82
0.80
0.02
(  0.13, 0.16)

0.79
0.67
0.12
(  0.04, 0.28)
0.80
0.68
0.12
(  0.02, 0.26)
0.78
0.68
0.10
(  0.04, 0.24)

Short
Long
S-Lc

1.02
1.09

Short
Long
S-Lc

1.00
1.00

Short
Long
S-Lc

0.97
1.04

0.86
1.05
 0.19n
(  0.31,  0.06)
0.86
1.02
 0.16n
(  0.30,  0.01)
0.85
1.02
 0.17
(  0.36, 0.02)

0.80
0.95
 0.16n
(  0.28,  0.03)
0.79
0.90
 0.11
(  0.25, 0.03)
0.81
0.94
 0.13
(  0.31, 0.05)

0.84
0.81
0.03
(  0.11, 0.18)
0.83
0.81
0.02
(  0.14, 0.19)
0.86
0.76
0.19
(  0.11, 0.31)

0.79
0.65
0.15n
(0.01, 0.29)
0.75
0.67
0.08
(  0.08, 0.24)
0.79
0.63
0.16
(  0.05, 0.37)

Short
Long
S-Lc

0.97
1.03

0.80
0.97
 0.17
(  0.37, 0.02)

0.76
0.94
 0.18
(  0.36, 0.01)

0.82
0.83
 0.01
(  0.23, 0.22)

0.79
0.51
0.28n
(0.06, 0.49)

Infd

12

24

36

1.06
1.19

0.96
1.07
 0.10
( 0.33, 0.13)
1.12
1.22
 0.11
( 0.57, 0.36)
1.02
1.26
 0.23
( 0.56, 0.10)

0.87
1.02
 0.16
(  0.37, 0.06)
1.12
1.12
-0.00
(  0.45, 0.44)
0.98
1.12
 0.14
(  0.43, 0.15)

0.94
0.95
 0.01
( 0.26, 0.24)
1.16
1.13
0.03
( 0.43, 0.49)
1.17
1.11
0.05
( 0.28, 0.39)

0.94
0.71
0.23
( 0.02, 0.47)
1.15
0.75
0.40
( 0.05, 0.85)
1.07
0.70
0.37n
(0.05, 0.69)

1.14
1.07
0.06
( 0.24, 0.37)
1.02
1.13
 0.11
( 0.33, 0.11)
0.94
1.08
 0.14
( 0.30, 0.02)

1.03
1.04
 0.01
(  0.30, 0.28)
0.94
1.08
 0.14
(  0.34, 0.06)
0.85
0.98
 0.12
(  0.27, 0.03)

1.07
1.05
0.02
( 0.33, 0.35)
1.00
0.90
0.11
( 0.13, 0.34)
0.89
0.90
 0.01
( 0.18, 0.17)

1.05
0.88
0.18
( 0.15, 0.51)
1.03
0.72
0.30n
(0.08, 0.53)
0.87
0.72
0.15
( 0.02 ,0.32)

0.97
1.10
 0.14
( 0.29, 0.02)

0.87
0.98
 0.11
(  0.25, 0.04)

0.91
0.85
0.07
( 0.11, 0.24)

0.86
0.78
0.09
( 0.08, .26)

1
1.11
1.33
1
1.07
1.15
1

1.09
1.25
2
1.12
1.34
1
1.07
1.15
1

1.07
1.15
2

Pe

Infd

0.87
2
0.82
2
0.73
2

0.46
2
0.08
2
0.63
1

0.05
1

p-valueo0.05, underlined symptoms have changed statistically signicantly in comparison with symptom level at 3 months, and symptoms in italics have decreased statistically signicantly below 0.9 on the SCL-90-GSI scale.
a

Good values of the individual suitability measure.


Poor values of the individual suitability measure.
c
Mean value difference of SCL-90-GSI between short-term and long-term therapy.
d
Inference: 1 Short-term therapy equally or more benecial; 2=Long-term therapy more benecial; 3=Neither short-term nor long-term therapy benecial.
e
P-value for interaction between the suitability measure and the therapy group throughout the follow-up.
f
Simplied covariance structure.
b

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

Flexibility of interactionf

Therapy

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

169

Table 4
Mean values (95% condence intervals) of SCL-90-GSI in short-term and long-term therapy at 3-, 7-, 12-, 24- and 36-month follow-up according to the values of the
Suitability for Psychotherapy Scale (SPS) score.
Short-term therapy

Suitability for
Psychotherapy
Scale (SPS) scorea

7 categories
0: All values good

27

1: 6 values good

41

2: 5 values good

47

3: 4 values good

39

4: 3 values good

17

5: 2 values good

13

6: 1 value good

7: All values poor

0.93 0.74
(0.55,
1.02 0.88
(0.72,
0.99 0.94
(0.79,
1.04 0.85
(0.69,
1.13 1.02
(0.76,
1.03 1.05
(0.79,
1.27 1.19
(0.81,
1.31 1.30
(0.86,

Long-term therapy

12

24

36

0.70
(0.51,
0.93
(0.79,
0.70
(0.55,
0.76
(0.61,
0.98
(0.73,
0.85
(0.60,
1.19
(0.78,
1.45
(1.05,

0.78
(0.56,
0.90
(0.72,
0.80
(0.62,
0.80
(0.61,
0.98
(0.67,
1.03
(0.70,
1.32
(0.85,
1.43
(0.99,

0.67
(0.45,
0.85
(0.67,
0.73
(0.55,
0.84
(0.66,
0.95
(0.61,
1.03
(0.73,
1.16
(0.70,
1.49
(0.98,

13

0.87 0.89
(0.62,
1.06 1.11
(0.94,
1.05 0.91
(0.76,
1.26 1.21
(0.94,
1.30 1.06
(0.56,
1.51 1.31
(0.80,
1.13 1.27
(0.48,
1.45 0.94
(0.05,

12

24

36

0.89
(0.63,
0.95
(0.78,
0.87
(0.73,
1.01
(0.77,
1.30
(0.99,
1.05
(0.67,
1.21
(0.63,
1.14
(0.32,

0.76
(0.46,
0.81
(0.62,
0.74
(0.58,
0.82
(0.54,
0.94
(0.57,
1.40
(0.93,
1.19
(0.63,
1.17
(0.19,

0.61
(0.32,
0.67
(0.48,
0.61
(0.46,
0.78
(0.51,
0.61
(0.29,
0.72
(0.21,
0.84
(0.36,
1.27
(0.33,

Infb Pc
0.70

0.93)
1.03)
1.08)
1.00)
1.28)
1.31)
1.57)
1.73)

0.89)
1.08)
0.84)
0.92)
1.23)
1.10)
1.60)
1.84)

1.01)
1.08)
0.99)
0.98)
1.28)
1.35)
1.79)
1.88)

0.88)
31
1.04)
41
0.91)
17
1.02)
10
1.28)
9
1.32)
5
1.62)
2
2.00)

1.16)
1.28)
1.05)
1.48)
1.56)
1.82)
2.06)
1.82)

1.15)
1.11)
1.01)
1.25)
1.61)
1.43)
2.05)
1.97)

3 categories
Values 03 combined 154 1.00
Values 46 combined 38
Value 7

1.06)
1.01)
0.91)
1.10)
1.30)
1.87)
1.75)
2.14)

0.89) 1
0.87) 1
0.77) 1
1.06) 1
0.94) 2
1.22) 2
1.33) 2
2.20) 3
0.83

0.86
0.78
0.82
0.78
102 1.06 1.02
0.92
(0.78, 0.94) (0.70, 0.86) (0.72, 0.91) (0.69, 0.87)
(0.92, 1.12) (0.83, 1.03)
1.12 1.05
0.95
1.05
1.03
24
1.35 1.23
1.18
(0.88, 1.22) (0.79, 1.11) (0.85, 1.25) (0.84, 1.22)
(0.97, 1.49) (0.95, 1.41)
1.31 1.31
(0.87, 1.76) 1.43
1.50
2
1.45 0.94
1.15
(1.00, 1.87) (1.00, 1.99)
(0.01, 1.88) (0.28, 2.02)

0.79
(0.68, 0.90)
1.12
(0.86, 1.38)
1.18
(0.15, 2.20)

0.65
(0.54, 0.76) 1
0.79
(0.55, 1.04) 2
1.28
(0.27, 2.28) 3

Underlined symptoms have changed statistically signicantly in comparison with the symptom level at 3 month, and symptoms in italics have decreased statistically
signicantly below 0.9 on the SCL-90-GSI scale.
a
The values of the 7 single dichotomous suitability measures (good 0, poor 1) were summed up (07). Values 03 of the cumulative score were considered low,
values 46 intermediate and value 7 high.
b
Inference: 1 Short-term therapy equally or more benecial, 2 Long-term therapy more benecial and 3 Neither short-term nor long-term therapy benecial.
c
P-value for interaction between the suitability measure and the therapy group throughout the follow-up.

B. Mostly poor values in suitability


measures (4-6)
Short therapy (n = 38)
Long therapy (n = 24)

C. All values poor (7)


Short therapy (n =6)
Long therapy (n =2)

1.5

1.5

0.5

SCL-90-GSI

1.5

SCL-90-GSI

SCL-90-GSI

A. Mostly good values in suitability


measures (0-3)
Short therapy (n = 154)
Long therapy (n = 102)

0.5

0
0

9 12
18
24
Follow-up time (months)

Baseline Short therapy ends

36

Long therapy ends

0.5

9 12
18
24
Follow-up time (months)

Baseline Short therapy ends

36

Long therapy ends

9 12
18
24
Follow-up time (months)

Baseline Short therapy ends

36

Long therapy ends

Suggested cut of value for recovery from psychiatric symptoms


Statistically significant difference (p < 0.05) between short-and long-term therapy .

Fig. 2. Changes in psychiatric symptoms (SCL-90-GSI) according to SPS score.

Most of the studies so far have concentrated on the prediction


of single suitability measures, whereas little is known about the
simultaneous effect of suitability measures (Brodaty et al., 1982;
Jorgensen et al., 2000; Cromer and Hilsenroth, 2010). The few
studies using global suitability measures (Brodaty et al., 1982;
Alpher et al., 1990; Safran et al., 1993; Jorgensen et al., 2000)
have, however, found them to be especially good predictors of
psychiatric symptoms, thus suggesting a possible cumulative
effect of single suitability measures. In this study as well,
the cumulative score of seven single suitability measures was
found not only to predict psychiatric symptoms, but also to
reliably differentiate between the short- and long-term therapy
outcomes.

Few studies have considered the differential prediction of the


same suitability measures on symptoms in different types of
therapies (Sotsky et al., 1991; Blatt et al., 1995; Piper et al., 1998;
McBride et al., 2006; Joyce et al., 2007; Marshall et al., 2008).
All of these studies concentrate on short-term therapies and have
found some differences in the prediction of suitability measures
for different types of short-term therapies. No notable differences
in the prediction of SPS on short-term psychodynamic psychotherapy or solution-focused therapy were found in the Helsinki Psychotherapy Study (Laaksonen et al., 2013).
Although the prediction of suitability measures does not seem
to differ between short-term therapies, it has been suggested that
patients assessed with good values in suitability measures gain

170

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

more from short-term therapies, whereas patients assessed with


poor values need long-term therapy to recover (Hoglend, 1993).
The present study is the rst to conrm this hypothesis for ve of

the seven suitability measures, thus suggesting, together with the


former evidence on equal prediction in the two short-term
therapies (Laaksonen et al., 2013), that the choice between the

Table A1
Description and classication of the Suitability for Psychotherapy Scale (SPS).
Variable
DOMAIN 1: Ego strength
Modulation of affects
1 Contact with both positive and negative affects, good ability for adequate affect control
2 Mild defensiveness, mainly good modulation of affects
3 Somewhat defensiveness without major impact on the interview, restricted contact with affects
4 Signicant defensiveness, narrowing the contact with interviewer
5 Very pronounced defensiveness or moderate affective outbursts
6 Disaffected or affective outbursts
7 Affective stupor or agitation
Flexibility of interaction
1 Very good, exible and natural dialog
2 Good, mild difculty in collaboration or exceeding time limits
3 Fair, temporary breaks of narration
4 Restricted, does not take notice of time limits
5 Signicantly restricted, nonintegrated separate themes
6 Dysfunctional dialog and loss of time perspective
7 Very poor, whole interview dysfunctional
Self-concept in relation to ego ideal
1 Adequate balance between self and ideal self
2 Belittling of self, ideal self attainable
3 Self denigration, ideal self difcult to attain
4 Some unrealistic features in self and ideal self
5 Self denigration and grandiose features in ideal self
6 Unrealistic and grandiose features in self structure and ideal self
7 Denigration of self and grandiose ideal self demands, leading to stagnation
DOMAIN 2: Self-observing capacity
Reective ability
1 Very good, psychological elaboration and consideration of time span
2 Good, mild restrictions, consideration of time span
3 Fair, defensive narrowness of reective ability, consideration of time span
4 Restricted to external facts, consideration of time span
5 Signicantly restricted, narrow time span
6 Severe restriction to only present situation
7 No psychological reective ability
Trial interpretation
1 Experience-near elaboration at rst interview
2 Experience-near elaboration at 2nd or 3rd interview
3 Non-experiential or delayed elaboration
4 Responsiveness with extra material and no elaboration
5 Responsiveness with no extra material and no elaboration
6 No responsiveness to trial interpretation
7 No trial interpretation made by the interviewer
Motivation
1 Very good, based on own activity and long-term consideration, desire for introspection
2 Good, based on own activity, introspective needs less prominent
3 Good, problem relief main reason for seeking treatment
4 Quite good, problem relief almost the only reason for seeking treatment
5 Fair, ambivalent, based signicantly on others suggestions
6 Poor, signicant ambivalente
7 No motivation for therapy
DOMAIN 3: Nature of problems
Focus
1 Circumscribed and experiential focal conict present at rst interview
2 Circumscribed and experiential focal conict present at 2nd or 3rd interview
3 Specic focal conict with no experiential derivative
4 Global problem area and theoretically derived focal conict with no clinical vignette
5 Unspecic and mainly theoretical focus, e.g. dependency problem
6 Very difcult to determine a focus for short-term therapy
7 Impossible to determine any focus

Classication of the values 17 of the suitability measures into good and poor values.

Dichotomous classicationa

Good (13)
Poor (47)

Good (14)
Poor (57)

Good (14)
Poor (57)

Good (13)
Poor (47)

Good (14)
Poor (57)

Good (12)
Poor (37)

Good (12)
Poor (37)

M.A Laaksonen et al. / Psychiatry Research 208 (2013) 162173

two therapies of different length is apparently more relevant than


the choice between two therapies of the same length, but of
different types.
4.2. Methodological considerations
The present study had several strengths: the large sample size,
the long follow-up time, the frequent outcome assessments, and
the reliable SPS suitability assessment method. The SPS
(Laaksonen et al., 2012) assesses seven different aspects of
patients psychological capacity, considered relevant for evaluating suitability for different forms of short- and long-term therapy
(American Psychiatric Association, 1985; Blenkiron, 1999), based
on an interview which is considered a more reliable and objective
method for assessing patient suitability than a self-report questionnaire. The reliability of trained interviewers assessments of
both individual and cumulative suitability measures, considered
quite complex phenomena difcult to assess, was shown to be fair
or good, except for focus. The poorer reliability of assessment of
focus may be due to confusion over whether it should have been
evaluated based on patients ability to focus in session or interviewers ability to formulate a focus based on patients narration
(Safran et al., 1993) assessment of focus thus warrants special
attention when training for the method in future. Another
strength of this study was considered to be the use of new more
comprehensive criteria for the prediction of suitability factors on
outcome of psychotherapy, assessing the statistical signicance of
different dimensions of change, including both a statistically
signicant change in outcome in time and a statistically signicant difference in outcome between short- and long-term therapies. The patients were further classied into different prognosis
groups using inference based on these criteria.
There are, however, also several issues that may complicate
the interpretation of the results. The general limitations related to
the design of the Helsinki Psychotherapy Study (i.e., lack of
manuals and blindness of raters making follow-up assessments)
are discussed in more detail elsewhere (Knekt et al., 2008), and
only the limitations specic to this study are addressed here. First,
because of the long follow-up, no non-treatment control
group could be included for ethical reasons. Consequently, the
possible reduction in symptoms due to factors other than the
treatments given, such as regression to the mean, could not
be controlled. Second, although potential confounding factors
(i.e., socio-economic factors, psychiatric history and variables
related to social functioning) were adjusted by modeling, the
possibility that residual confounding may have biased the results
cannot be fully excluded. Third, the compliance of study treatment (i.e., withdrawal from treatment after randomization and
discontinuation of therapy) may potentially cause bias in the
data. Adjustments for withdrawal or discontinuation in as-treated
analysis did not, however, notably alter the results from those of
the intention-to-treat analysis. Fourth, since it was unethical to
deny use of auxiliary treatment during the 3-year follow-up, use
of psychiatric medication, therapy or psychiatric hospitalization
also contributed to compliance (Knekt et al., 2011). The reasons
leading to the use of auxiliary treatment and the effect it has on
the outcome apparently are important issues in suitability
research and in psychotherapy research in general, and accordingly deserve more attention in the future. Fifth, although no
notable differences were found between the intention-to-treat
and the as-treated analysis carried out based on both the original
and imputed data, possible non-ignorable dropouts may bias the
anen

results (Hark
et al., 2005). Sixth, the follow-up time in this
study was 3 years from the start of the treatments, during which
patients were provided with either short-term therapy, followed
by no treatment, or long-term therapy, and the outcome of these

171

therapies was evaluated at the 3-year follow-up point. This study


thus provides information on the sufciency of short-term therapies in the long run, even after the end of the treatments, but to
make sure that the conclusions on the sufciency of long-term
therapy remain in the long run, a longer follow-up time is needed.
Seventh, due to the multiple comparisons performed and the
relatively small amount of data in different subgroups (especially
in the subgroup of patients with all values of the suitability
measures poor), the possibility of a chance nding cannot be
excluded and further research is thus needed to conrm these
ndings. Finally, more research is needed to clarify whether the
SPS predicts and differentiates similarly the outcome of other
types of psychotherapies.
In conclusion, the amount of therapy that patients suffering
from axis I disorders need to recover may be predicted by
assessing their personality measures before the start of therapy.
Patients assessed to have mainly good values of these suitability
measures can apparently be successfully treated with short-term
therapy, whereas patients assessed with having mainly poor
values of suitability measures seem to need long-term therapy
or some other treatment to recover. More research is needed to
verify these ndings and to demonstrate the value of this
prognosis in practice.

Acknowledgment
The study was nancially supported by the Academy of Finland
(Grant nos. 138876 and 253088) and the Social Insurance Institution,
Finland. The nancial support of the Emil Aaltonen Foundation and
the Foundation for Psychiatric Research in Finland to the rst author
is also gratefully acknowledged.

Appendix A1
See Table A1.
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