It is a well known fact that the majority of patients in psychiatric care respond inadequately to the treatments they are given. This is exemplified in large scale psychotropic medication trials (See STAR-D study). In general, using the notion of effect size
 most empirically validated psychotherapy treatments tend to help about half of treated patients to a substantial or moderate degree, and about a further quarter of patients to some extent, while the remaining patients usually continue unchanged or are to some extent deteriorated
. Using the criteria of clinically significant change
, the average recovery rate for formal psychotherapeutic treatments in clinical trials (based on meta-analytic studies across a wide variety of psychological treatment models and formats) is between 50 and 60 per cent
. Consequently, by this definition, as much as 40 to 50 per cent of patients remain, in terms of clinically meaningful change, unimproved or are worsened at termination. The known deterioration rates from such trials are relatively consistent and indicate that five to ten per cent of patients participating report themselves as reliably worse off after treatment than before
. In what is often denoted routine care, i.e. treatment as it is delivered in naturalistic settings without specific supervision of therapists and specific systems for focusing the delivered treatments, the rates of recovery appear to be smaller, so that even more patients are expected to remain unchanged or deteriorate in everyday psychotherapeutic practice
We thus have a situation in which a relatively large proportion of patients in mental health care must be classified as non-responders or negative responders, i.e. they do not benefit from the treatments with which they are provided, or even become worse during treatment. This state of affairs is, or at least should be, distressing to mental health professionals and psychotherapy researchers alike, and any chance of remedying it should be a highly valuable contribution to the mental health care community and the many patients seeking treatment.
There has been very limited research on patients who don’t respond to psychotherapy. It therefore remains largely unknown whether changes in treatment formats, treatment dose, or treatment content could improve outcome for at least a portion of these patients. However, indirect knowledge of this group comes from studies on the treatment of patients with personality disorders
[5–8], from studies of non-response to antidepressant medication for depression
, and from studies of the effects of process-outcome feedback systems on patient responses to treatment
. Generally, the findings indicate that the probability of non-response or negative response increases with more severe symptoms, with more profound functional impairment, with more problems in interpersonal relatedness, and with the presence of personality disorder. Problem complexity as evidenced by comorbidity on Axis I and/or II and problem chronicity also appears to predict treatment failure in short-term treatments and has been proposed as an indicator for more complex and broadband treatment
. From studies on session by session feedback to therapists and patients about treatment response through monitoring levels of self-reported distress, interpersonal problems, and social role functioning at the beginning of every session, it does, however, appear to be clear that such feedback reduces the prevalence of negative change in psychotherapy, thereby increasing overall effectiveness of treatments
Reviewing the literature, it becomes clear that few studies have selected patients from the group of non-responders to psychotherapy for systematic intervention and scientific investigation. Furthermore, to our knowledge, no studies have specifically selected patients primarily based on repeated non-response to treatment and attempted systematic, customized psychotherapeutic intervention with this group. Such studies could yield important knowledge about the possibilities of finding feasible strategies for overcoming this unfortunate state of affairs. If it was possible to identify specific principles of customized treatment that could lead to better outcomes of psychotherapeutic intervention for patients belonging to this group, it would imply significant relief and increase in quality of life for a large number of patients. It could also result in considerable social-economic savings associated with reduced treatment costs and lower reliance on welfare services for a substantial number of those disabled by persistent and unrelenting mental disorders not responsive to traditional treatments.
Accordingly, the current project was designed and implemented. With the aim of relieving the suffering of patients having experienced repeated non-response to treatment efforts, a time-limited residential treatment program was devised. The project was based at the psychodynamic unit at "Thorsberg", the Residential Facility of the Drammen District Psychiatric Center, Norway. The treatment program was primarily directed towards relieving treatment resistant anxiety- and depressive disorders with and/or without comorbid Axis II disorder. This group of patients presumably represents the majority of non-responding or treatment resistant referrals (due to the prevalence of these disorders). As a criterion of inclusion, patients were to have received three or more qualified and documented treatment attempts, defined as separate medical or psychosocial/psychotherapeutic treatment series aimed at the disorder(s) for which they currently were referred for treatment.
Considering the long-standing and chronic disorders suffered by these patients and their often years-long treatment histories, it was clear that the treatment program would have to be organized according to fundamentally different principles than those guiding routine care. First, it was decided that patients were to be treated in residential care in order to increase the probability of treatment compliance (in the medical sense of the word) and reduce the risk of drop-out. Secondly, a clear and non-debatable time limit was provided, with a circumscribed date for terminating treatment for all patients (at the end of eight weeks of residential treatment). Thirdly, a highly intensive treatment and intervention program was devised with multiple treatment components delivered every day. The treatment program was to extensively combine individual psychotherapy, group-psychotherapy, medical/psychopharmacological treatment (if necessary), and various therapeutic activities in groups including body awareness training, art therapy, structured psycho-education, moderate physical exercise, psychosocial training, and milieu therapy. As a theoretical system to inform systematic understanding of patients and all treatment components, the psychotherapeutic model and metapsychology originally described by Davanloo
 (Intensive Short-term Dynamic Psychotherapy, ISTDP), along with the more general affect theoretical model delineated by affect integration theory
[12, 13] were chosen. This meant that a fundamental understanding of psychopathology as failed integration of affect, cognition, and behavior was adhered to, with a specified focus on the mobilization of warded off, repressed, or avoided affect associated with pathogenic ruptures to the patient’s bonds with attachment figures throughout the course of development.
Arguably, Davanloo’s ISTDP is the psychotherapy model in the literature today that most clearly conceptualizes systematic work with treatment resistance, at least in the traditional psychodynamic sense of that word. ISTDP posits a conceptually integrated and extensive set of interventions and intervention modes that are specifically directed at dealing with those maneuvers patients often consciously or unconsciously resort to in order to avoid genuine emotional closeness, to water down strong affect, to remain passive, compliant, or defiant and so on and so forth. These processes presumably contribute substantially to the generation of obstacles to treatment and consequent treatment failure if not effectively and specifically dealt with. For this reason we chose to use the technical intervention apparatus described and detailed by Davanloo and others (e.g.
[14, 15]) as a basis for the individual psychotherapy courses, and to use adjusted and adapted versions of this system for guiding intervention in other components of the treatment.
In general, ISTDP is a fairly well documented treatment for a number of mental disorders. It has been demonstrated to be clinically effective and cost-effective in case series of mixed psychiatric samples
[16, 17]. Also, it has been shown to be effective and cost effective with a previous (but small) sample of patients with treatment resistant depression
, in personality disorder
[5, 19–21], and in a specialized hospital setting for treating severe cases of borderline personality disorder, most of which had had previous treatment but failed to benefit
. It has been studied in resistant and complex populations in several case series and randomized controlled trials
. It has been demonstrated in the National Health Services in the UK’s "Pathfinder" project to produce good treatment effects in patients resistant to other treatment efforts
. It has been found effective for patients with chronic somatic conditions with functional movement disorders
, with chronic pain
 and with medically unexplained symptoms with repeated emergency visits
. Thus, there is a fairly good empirical basis for choosing the ISTDP model as a basis for a treatment program aimed at relieving the suffering of patients characterized by non-response to previous treatment attempts.
The treatment philosophy and treatment principles of ISTDP have been described in detail elsewhere, e.g.
[5, 11, 15, 22]. Here it suffices to say that the main emphasis of ISTDP is to rapidly help the patient acknowledge, identify, experience, and express unconscious and warded-off affects or emotions that theoretically are postulated to produce unconscious anxiety, symptom disturbances, and various defensive strategies that become interpersonally maladaptive and may produce characterological disturbances within the patient. The main technical interventions are to detect, clarify and challenge affect-avoiding strategies or defenses in systematic collaboration with the patient, while inviting and encouraging clear awareness and deep experience of warded-off feelings. This process, when effectively executed, mobilizes what Davanloo called "complex transference feelings" with the therapist, thereby actualizing the patient’s most pressing patterns of attachment-related affect and his most characteristic coping strategies with these affects within the therapeutic relationship. Simultaneously, the conscious and unconscious therapeutic alliance is mobilized, producing a force within the patient that allies with the therapist in the face of avoidance strategies and resistances
. In turn, this leads to a reduction in defensive coping so that the patient can more directly work through unresolved feelings related to broken attachments in the past and subsequent trauma
The treatment program and its quality control system were designed so that comprehensive and reliable data would be available for determining the ultimate effectiveness of the treatments delivered. Such documentation was seen to be paramount in order to justify the relatively large investments of resources and money that is necessary for offering residential care for patients that statistically would be likely to fail also this treatment. A substantial number of process- and outcome indicators were therefore implemented as standard procedure. This quality control system implied that all individual treatment sessions were to be videotaped, the systematic use of diagnostic and functional interviews prior to, at termination and follow-up after termination, and that an extensive battery of self-report measures were to be administered prior to treatment, during treatment, and after treatment. Furthermore, a system for session-by-session process and progress tracking was to be implemented, so that therapists would have continuous feedback about the development of all patients. The follow-up period post treatment termination was defined to be at least 12 months. The research relevance of this data was immediately acknowledged; therefore a research protocol was detailed that was to hold international standards in terms of assessment procedures and methodological design.
The data gathered through the "Drammen Project" are unique in that they combine the selection of a group of patients previously not systematically investigated in the established literature, while at the same time delivering a multifaceted treatment program of unusual intensity based on a treatment model that appears especially well-suited for the task of relieving treatment resistance. These data thus carry potentially important insights that may be highly valuable to both psychotherapy research and the psychotherapy community.
Main research objectives for the Drammen project
The following research objectives can be detailed as being at the heart of the research part of the Drammen Project for treating patients with treatment resistant mental disorders.
What is the effectiveness of an intensive multifaceted time limited treatment program based on principles from ISTDP for patients with known treatment resistant disorders at termination and follow-up after treatment?
Which process-outcome mechanisms may foster or conversely hinder adequate treatment response for patients entering the program?
Which patient- and therapist factors predict poor and good response for patients entering the program?