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John Markowitz, MD

I am not a psychoanalyst, although I’m married to one and was an adherent psychodynamic therapist in her Panic-Focused Psychodynamic Psychotherapy studies.¹ I got basic training as a resident at the Payne Whitney Clinic in its psychodynamic heyday under Bob Michels, and I had exactly four years of psychoanalysis with a Columbia training analyst (beginning and ending on my mother’s birthday). I wanted, though, to do psychotherapy research, for which psychoanalysis has unfortunately not been a fertile field. When the late Gerald Klerman came to Cornell Medical College and I had graduated to the junior faculty, I got the chance to learn and study Interpersonal Psychotherapy (IPT).

IPT is a manualized, time-limited, affect-focused psychotherapy based on the attachment principles of John Bowlby and the interpersonal emphasis of Harry Stack Sullivan.² It focuses on the connection between mood and interpersonal life circumstance in the context of rapidly treating mood and, increasingly, other DSM disorders. IPT does not focus on childhood nor address the transference, focusing instead on the patient’s life outside the office. (Informed IPT therapists note transferential and childhood issues in assessing patients but do not directly employ them.) Like me, then, IPT is sympathetic to but differs from psychodynamic therapy: both are affect-focused treatments.³ 

For more than three decades I have conducted comparative clinical research comparing psychotherapies to one another and to pharmacotherapy. My first big psychotherapy study in the 1990’s, a National Institute of Mental Health-funded trial conducted by the late Samuel Perry, M.D. (a psychoanalyst), compared IPT to cognitive behavioral therapy (CBT), imipramine, and supportive psychotherapy for depressed HIV-positive patients.⁴ Other studies have assessed IPT treatment outcomes for depressed patients post-miscarriage,⁵ with infertility,⁶ and with breast cancer;⁷ dysthymic disorder, with and without alcohol abuse;^8,9 borderline personality disorder;¹⁰ and most recently, posttraumatic stress disorder.¹¹

Each disorder and treatment population requires adaptation of the treatment manual, but the fundamental approach remains the same, and results have helped to define not only the efficacy of treatments (i.e., that they work) but which treatment works better for which patients. It’s exciting clinical work. Along the way, we wrote a manual for Brief Supportive Psychotherapy (BSP) as a control therapy for IPT and CBT, which turns out to be a powerful affect-focused treatment in its own right.¹²

In 2019 I joined the American Psychoanalytic Association College of Research Fellows alongside Bart Blinder. The College is rightly concerned that the continuing allergy of psychoanalysis to outcome research risks consigning it to irrelevance. In today’s era, long after Freud, therapies need an evidence basis to show they work, and psychoanalysis lacks one. (Even with evidence, psychotherapies are on most often the defensive.^13,14)  Research has shown the benefits of time-limited psychodynamic therapies for particular disorders, but the field needs randomized controlled trials to show whom psychoanalysis helps and what advantages it may have over briefer treatments.

References

1. Milrod B, Chambless DL, Gallop R et al: Psychotherapies for panic disorder: a tale of two sites. J Clin Psychiatry 2016;77:927–935
2. Weissman MM, Markowitz JC, Klerman GL: The Guide to Interpersonal Psychotherapy. New York: Oxford University Press, 2018
3. Markowitz JC, Milrod BL: Affect-focused and exposure-focused psychotherapies. Am J Psychotherapy (submitted 4/15/23)
4. Markowitz JC, Kocsis JH, Fishman B, Spielman LA, Jacobsberg LB, Frances AJ, Klerman GL, Perry SW: Treatment of depressive symptoms in human immunodeficiency virus-positive patients. Arch Gen Psychiatry 1998;55:452-457
5. Neugebauer R, Kline J, Markowitz JC, Bleiberg K, Baxi L, Rosing M, Levin B, Keith J: Pilot randomized controlled trial of interpersonal counseling for subsyndromal depression following miscarriage. Journal of Clinical Psychiatry 2006;67:1299-1304
6. Koszycki D, Bisserbe J-C, Blier P, Claman P, Bradwejn J, Markowitz J: Interpersonal psychotherapy versus brief supportive therapy for depressed infertile women: a pilot randomized controlled trial. Arch Womens Ment Health 2012;15:193-201
7. Blanco C, Markowitz JC, Hellerstein DJ, Nezu A, Wall M, Olfson M, Chen Y, Levenson J, Onishi M, Varona C, Okuda M, Hershman D: A randomized trial of interpersonal psychotherapy, problem solving therapy, and supportive therapy for major depressive disorder in women with breast cancer. Breast Cancer Res Treatment 2019;173:353-364
8. Markowitz JC, Kocsis JH, Christos P, Bleiberg K, Carlin A: Pilot study of interpersonal psychotherapy versus supportive psychotherapy for dysthymic patients with secondary alcohol abuse or dependence. J Nerv Ment Disease 2008;196:468-474
9. Markowitz JC, Kocsis JH, Bleiberg KL, Christos PJ, Sacks MH: A comparative trial of psychotherapy and pharmacotherapy for “pure” dysthymic patients. Journal of Affective Disorders 2005;89:167-175
10. Markowitz JC, Bleiberg KL, Pessin H, Skodol AE: Adapting interpersonal psychotherapy for borderline personality disorder. J Ment Health 2007;16:103-116
11. Markowitz JC, Petkova E, Neria Y, Van Meter P, Zhao Y, Hembree E, Lovell K, Biyanova T, Marshall RD: Is exposure necessary? A randomized clinical trial of interpersonal psychotherapy for PTSD. Am J Psychiatry 2015;172;430-440
12. Markowitz JC: Brief Supportive Psychotherapy: A Treatment Manual and Clinical Approach. New York: Oxford University Press, 2022
13. Markowitz JC, Milrod BL: Post-pandemic psychotherapy: still under siege. Psychiatric Serv 2022;73:690-692
14. Markowitz JC, Milrod B: Lost in translation: the value of psychiatric clinical trials. J Clin Psychiatry 2022;83(6):22com14647

Recommended reading: references # 11, 13, 14

John C. Markowitz, MD, is a Professor of Clinical Psychiatry at the Columbia University Vagelos College of Physicians & Surgeons and a Research Psychiatrist at the New York State Psychiatric Institute in New York City. His work focuses on psychotherapy outcome research.