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Assessment methods for psychoanalytic observation

Löffler-Stastka, H., Stigler, K., (2011). Der Affektwahrnehmung und Affektregulation Q-sort-Test (AREQ): Validierung und Kurzform. [The Affect Experience and Affect Regulation Q-Sort Test (AREQ): validation and short version] PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie, 61, 225-232. DOI: 10.1055/s-0030-1263146
Löffler-Stastka, H. & Blüml, V. (2010). Assessment tools for affect regulation and quality of object relations in personality disorders: The predictive impact on initial treatment engagement. Bulletin of the Menninger Clinic, 74(1), 29-44. DOI: 10.1521/bumc.2010.74.1.29
Löffler-Stastka, H., Blüml, V. & Jandl-Jager, E. (2009). Voraussagekraft für die Therapie-Inanspruchnahme bei Persönlichkeitsstörungen: SWAP-200 und SKID-II im Vergleich [Predictive Power on therapy engagement in personality disorders: SWAP – 200 versus SCID-II]. PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie, 60, 342-349. DOI: 10.1055/s-0029-1238299

Brief Summary

Use of Q-sort assessment methods for diagnostic purposes and in treatment evaluation Objectives: Does quantifying psychotherapy research do justice to its subject matter? Methods: Q-sort techniques are presented for the assessment of personality pathology, mental and interpersonal problems, as well as for quantifying the psychotherapeutic process.

Results

In studies on psychotherapy planning we identified mechanisms characteristic of nonresponders which could be efficiently captured with q-sort methods. Fromthese clinically relevant intervention techniques can be derived. In psychoanalytic process research we operationalized relevant microelements in the patient-therapist interaction. Conclusions: Q-sort methods are efficient and helpful for studying research questions that are clinically relevant but often difficult to grasp as well as for dismantling studies. First, we investigated the validity of the prototype-matching, empirically based 200-item Shedler-Westen Assessment Procedure (SWAP-200) and its clinical utility for describing underlying dimensions of psychostructural organization and functioning. Patients (n = 306) from two psychoanalytic out-patient departments were included. Replicatory and exploratory factor analysis, correlation and discriminant validity statistics, and canonical correlation analysis were performed. Standard factor analysis revealed an eight-factor solution displaying a dimensional description of psychostructural personality organization (high functioning - neurotic/inhibited - borderline/emotionally dysregulated - psychotic/dissocial). Discriminant validity exists across the sample owing to high/poor psychological functioning. Canonical correlation analysis does not support the replacement of the Structured Clinical Interview for DSM-IV, but provides relevant implications for refining DSM-IV axis II. Support is given for the SWAP instrument in describing dimensional higher-order personality organization and psychostructural functioning. On the road to DSM-V, instruments are demanded that provide clinically meaningful information, for example, predictions about psychotherapy utilization. Comparison of five different instruments in a sample of 297 patients with personality disorders showed that the Structured Clinical Interviews for DSM-IV (SCID), SWAP-200, and the Inventory of Interpersonal Problems (IIP) lead to predictive models concerning initial therapy engagement. The Affect Experience and Affect Regulation Q-sort (AREQ) provided information concerning therapy rejection. The findings point to the importance of interpersonal, affective, and psycho-structural functioning in the diagnostic procedure of personality disorders. Concerning affect regulation, the empirically defined factors used in the Austrian sample of our study showed correspondences and an overlap with the factors derived from the psychoanalytic theory and the original factors of Westen and colleagues. This study confirms the importance of investigating the applicability of psychometric instruments in various clinical samples. The AREQ test can be used in the diagnostics and during the assessment of treatment. Special features of the sample (diagnostic interviews and therapy process data) as well as the raters' theoretical background are probably able to influence the resulting factor structure. The outcome of this study might be helpful for building up core concepts for the construction of new instruments.

Currently, the conceptualization and treatment of personality pathologies are mainly theory driven. The resulting categorical classification of personality disorders leads to inaccurate diagnoses and is therefore being criticized by many researchers and clinicians. A consensus exists that in the upcoming edition of the DSM (DSM 5), the classification of personality disorders should rather adopt a dimensional approach, where patients are assessed depending on their character traits, inner-defense mechanisms, and interpersonal functioning. However, the basis (theoretical or empirical) of this classification-system is still a topic of dispute. This study presents assessment methods based on both theoretical and empirical assumptions.

Objective

To determine whether psychodynamic instruments employed in psychoanalytic settings are also useful for measuring changes in personality pathology in psychiatric inpatient settings. Matched pairs between two groups of patients, one receiving outpatient psychoanalytic care, the other inpatient social-psychiatric treatment, were created and subsequently analyzed (mean observation period 20 ± 11 days). Patients were assessed using psychodynamic instruments measuring changes in quality of object relations (QORS) and affect regulation and experience (AREQ). To allow conclusions concerning the respective mechanisms of change, the influence of the therapeutic relationship, measured by using instruments evaluating transference (PRQ) and countertransference (CTQ) patterns, was also assessed. The instruments aforementioned were shown to be suited for both psychoanalytic and psychiatric patients. Typical short-term developments of the distinctive therapeutic procedures were evident; however, in both settings a positive working alliance was shown to be crucial for therapeutic progress.The psychodynamic instruments introduced in this study proved to be effective in measuring personality pathology in psychiatric inpatients and in helping clinicians throughout the indication and recommendation process during transition from inpatient to outpatient treatment. Since components of such assessment methods are being considered for DSM 5, their practical utility is shown in this study.

Contact

Assoc.Prof.in Priv.-Doz.in Dr.in Henriette Löffler-Stastka

Medizinische Universität Wien, Universitätsklinik für Psychoanalyse und Psychotherapie, Währinger Gürtel 18-20, 1090 Wien

Email: henriette.loeffler-stastka@meduniwien.ac.at

The mechanisms of change in the treatment of borderline personality disorder with Transference Focused Psychotherapy

Levy, K.N., Clarkin, J.F., Yeomans, F.E., Scott, L.N., Wasserman, R.H., Kernberg, O.F. (2006). The mechanisms of change in the treatment of borderline personality disorder with Transference Focused Psychotherapy. Journal of Clinical Psychology, 62(4), 481-501.

Summary

The authors address how Transference Focused Psychotherapy (TFP) conceptualizes mechanisms in the cause and maintenance of borderline personality disorder (BPD) as well as change mechanisms both within the patient and in terms of specific therapists’ interventions that engender patient change.

Mechanisms of change at the level of the patient involve the integration of polarized representations of self and others; mechanisms of change at the level of the therapist’s interventions include the structured treatment approach and the use of clarification, confrontation, and “transference” interpretations in the here and now of the therapeutic relationship. In addition, the authors briefly review evidence from their group regarding the following hypothesized mechanisms of change: contract setting, integration of representations, and changes in reflective functioning (RF) and affect regulation.

Contact

Kenneth N. Levy

Department of Psychology, Pennsylvania State University, 240 Moore Bldg., University Park, PA 16802

Email: klevy@psu.edu. Website: http://psych.la.psu.edu/directory/faculty-bios/levy.html

Relatedness and differentiation in the therapeutic dyad – an empirical investigation of psychoanalytic and psychotherapeutic change processes

Erhardt, I. (2014). Bezogenheit und Differenzierung in der therapeutischen Dyade. Eine empirische Untersuchung von psychoanalytischen und psychotherapeutischen Veränderungsprozessen {Relatedness and Differentiation in the Therapeutic Dyad. An Empirical Study of Psychoanalytic and Psychotherapeutic Change Processes}. Giessen: Psychosozial-Verlag.

Summary

Process-outcome research investigates not only treatment effectiveness; rather, what is really happening in the sessions and to which extent the captured patient-therapist interactions impact outcome. Therapeutic alliance was found to demonstrate the strongest association between process and outcome (Orlinsky et al. 1994; Norcross & Wampold 2011). The relevance on pre-treatment patient variables were emphasized in order to investigate differential treatment response (Blatt & Felsen 1993; Blatt & Shahar 2004; Clarkin & Levy 2004) and the importance of therapist variables for treatment outcome was demonstrated empirically (Luborsky et al. 1997; Wampold, 2001; Beutler et al. 2004).

The present study is a process-outcome study on psychodynamic and psychoanalytic long-term psychotherapy in which 29 audio-taped treatment processes from three psychotherapy archives were investigated.  Empirical rater-based research instruments were applied at four measure points (four sessions) in each treatment. The Psychotherapy Process Q-Set (PQS; Jones 2000; Ablon et al. 2012) was used to capture therapeutic process and treatment adherence, therapeutic alliance was measured with the California Psychotherapy Alliance Scales (CALPAS; Gaston & Marmar 1993), and psychic structure was assessed with the Differentiation-Relatedness-Scales (DR-S; Diamond et al. 2012). The latter was also used to capture therapeutic change in terms of level of self- and object-representations with repeated measurements. Pre-treatment patient variables were identified based on Blatt's personality theory of psychological dimensions “relatedness” and “self-definition“ which defines the distinction between anaclitic (dependent) and introjective (self-critical) personality configurations (Blatt & Ford 1994). A therapist variable was introduced in order to assess therapeutic style through differentiating between a „relational-oriented“ and a „differentiation-oriented“ style according to the same dimensions. Through matching patient and therapist variables, different dyads of “therapeutic match” were captured.

The main research questions where, whether there are differences in therapeutic process, alliance and outcome between treatments of anaclitic and introjective patients. In addition, hypotheses assume that alliance quality is associated with and predicts therapeutic change. Hypotheses suggest that there are process variables which distinguish between treatments with and those without clinical significant change overall patients and that specific therapeutic techniques are related to positive outcome. We assumed that a more complementary therapeutic match in terms of therapeutic stance and patient personality facilitate therapeutic change better than those which demonstrate more similarity.

Evaluation

Although, there is a small sample size, the findings are consistent with Blatt's theory (Blatt 2008). Results suggest e.g. that anaclitic patients feel more comfortable in relying upon therapists than introjective patients and that dealing with their self-image is very characteristic for introjective and not for anaclitic patients. No differences were found in terms of outcome between patient groups and between treatment groups. An association between therapeutic alliance and therapeutic change was found as well as a moderating effect of alliance. It seems that a better quality of therapeutic alliance leads to better patient working capacity and which is also associated with positive therapeutic change. More than a dozen process variables were identified which distinguish between treatments with and those without positive outcome overall patients, such as the degree of therapist's empathy and patient's compliance. Furthermore, only two therapeutic techniques were identified which are associated with therapeutic change. Therapeutic match seems to impact therapeutic outcome if there is a complementary match (e.g. anaclitic patients with differentiation-oriented therapists as well as introjective patients with relatedness-oriented therapists) than concordant matches (patient and therapist variables which are related to the same psychological dimension within each dyad). Clinical implications are discussed in terms of interaction between patient personality and therapist variable and therapeutic alliance. Limitations of the study amongst others are the small sample size and diagnostic heterogeneity of the patients. Further studies should replicate the objectives with bigger samples and include not only rater-based perspective but also other outcome measures.

Contact

Dr. phil. Dipl.-Psych. Ingrid Erhardt

Praxis für Psychoanalyse & Psychotherapie

Rosenheimer Str. 2; D - 81669 München

Email: erhardt.ingrid@gmail.com

Moderators of change in psychoanalytic, psychodynamic, and cognitive-behavioral therapy

Huber, D., Henrich, G. & Klug, G. (2013). Moderators of change in psychoanalytic, psychodynamic, and cognitive-behavioral therapy. Journal of the American Psychoanalytic Association, 61, 585-589. 

Summary

The present study focuses on the examination of moderators of change during psychotherapy. Outcome research in psychotherapy has proceeded remarkably, and that the effects of psychotherapy are statistically and clinically significant is empirically well founded. But “much more research needs to be conducted before the exact relationship between the process of the therapy and its outcome will be known” (Lambert and Ogles 2004). For that reason, the focus of psychotherapy research has shifted from investigating outcome to a process-outcome approach. A moderator is “a characteristic that influences the direction or magnitude of the relationship between an independent and a dependent variable” (Kazdin 2007). Moderators precede treatment and are not correlated with it. Identifying them helps in the prognosis of a course of therapy and in matching different patients to treatments.

The empirical basis of the process-outcome study is the Munich Psychotherapy Study (MPS), a prospective, comparative process-outcome study that evaluates the effectiveness and course of three different long-term psychotherapies: psychoanalytic (PA), psychodynamic (PD), and cognitive-behavioral (CBT) for a diagnostically homogenous sample of depressed patients. Patients seeking treatment for unipolar depression, single-episode or recurrent, and meeting the inclusion criterion were asked to participate in the study. The inclusion criterion was a primary diagnosis of a moderate or severe episode of major depressive disorder (ICD-10 F 32.1/2 or DSM-IV 296.22/23); a recurrent depressive disorder, current episode moderate or severe, without psychotic symptoms (ICD-10 F 33.1/2 or DSM-IV 296.32/33); or a double depression. Thirty-five patients were assigned to PA, 31 to PD, and 34 to CBT. Psychoanalytic therapy (PA) was operationalized as a therapy with a session frequency of three times a week, with the patient lying on the couch. Psychodynamic therapy (PD) was operationalized as a therapy with one session a week, in a face-to-face setting. Cognitive-behavioral therapy (CBT) was operationalized as a therapy with one session a week.

For this study, the outcome measure battery included the Beck Depression Inventory (BDI) on a symptomatic level, the Inventory of Interpersonal Problems (IIP) on an interpersonal level, and the Scales of Psychological Capacities (SPC) on an intrapsychic level. Outcome measurement points were pre-treatment and post-treatment. The following independent variables considered as putative moderators were assessed at pre-treatment: age, sex, partnership status, duration of depressive disorder since onset, and prior therapies, as well as observer-rated motivation for therapy and diagnosis of personality disorder during a clinical intake interview. Also included were the patient-rated Emotional Lability and Extroversion scale of the Freiburg Personality Inventory (FPI) and the therapist-rated subscale HAQ2: satisfaction with therapeutic relationship of the Helping Alliance Questionnaire (HAQ).

To show that the independent variables listed above are moderators of treatment effects, they were entered into a stepwise logistic regression analysis. Treatment modality (PA, PD, CBT) was included as the first step. The analysis was repeated with the dependent variables BDI, IIP, and SPC. The treatment effect was assessed as “clinical significance”.

The results are presented as odds ratios (ORs). Stepwise logistic regression analysis yielded that the Emotional Lability scale of the FPI (OR = 1.47) and diagnosis of a personality disorder (OR = 3.82) both negatively predicted outcome in the BDI. Partnership status (OR = 3.52), therapy dose (OR = 1.02) and satisfaction with therapeutic relationship (OR = 3.84) predicted positive outcome when assessed with the IIP. Only PA positively predicted outcome (OR = 4.1) when structural change (SPC) was the target variable.

Evaluation

Symptom improvement was negatively predicted by both self- and observer-rated personality impairment. Treatment parameters were the predominant predictors of positive outcome beyond symptoms. When structural change was the target variable, only PA predicted positive outcome. These findings lend support to the hypothesis that more intense and time-consuming therapies are needed to accomplish benefits on the interpersonal and intrapsychic level.

Contact

Prof. Dr. Dr. Dorothea Huber

Klinik für Psychosomatische Medizin und Psychotherapie. Klinikum München Sanatoriumsplatz 2, 81545 München; International Psychoanalytic University, Berlin

Email: D.Huber@lrz.tu-muenchen.de

Interactive regulation processes and their relationship with psychotherapeutic changes - Chilean Millennium Nucleus: “Psychological intervention and change in depression” Process Study 1.

Tomicic, A., Martínez, C., & Krause, M. (2015). The sound of change: A study of the psychotherapeutic process embodied in vocal expression. Laura Rice ideas revisited. Psychotherapy Research, 25 (2), 263-267.
Martínez, C., Tomicic, A., Medina, L., & Krause, M. (2015). A microanalytical look at mutual regulation in psychotherapeutic dialogue: Dialogic Discourse Analysis (DDA) in episodes of rupture of the alliance. Journal Research in Psychotherapy: Psychopathology, Process and Outcome (RIPPPO), in press.
Martínez, C., Tomicic, T., Salas, C., Rivera, M. J., & de la Cerda, C. (2015). Función Reflexiva en Primeras Entrevistas de Psicoterapia: Un Estudio Exploratorio. Revista Argentina de Clínica Psicológica, in press.
Martínez C., Tomicic, A., & Medina, L. (2014) Psychotherapy like discursive genre: A dialogic outlook to a time-limited psychotherapy. Culture & Psychology, 20 (4),501-524.

Background

This research line is based on the evidence from infant development psychodynamic research, relational neuroscience and attachment theory.

We have assumed “Regulation” as a core concept because the regulatory processes are involved in all types of interactions, but within significant relationships, like psychotherapy, these are reshaped changing the problematic ways we used to relate with the others and ourselves. 

We consider the regulatory process (a) as a permanent phenomenon, (b) that occurs with different degrees of consciousness, (c) that involves different psychological abilities (vg. mentalizing), and (d) which is related with phenomena like coordination, synchrony, attunement and fit. This research line is interested in comprehending mutual regulatory processes involved in the construction, development and maintenance of the psychotherapeutic relationship.

Research questions

How is related the mutual regulation between the participants and the psychotherapeutic change? What kind of changes occurs and in which dimensions during the psychotherapeutic process?

How “the change” develops within the patient-therapist interaction and through the psychotherapeutic process? Which are the temporal dynamics of each kind of change?

What kind of problems and/or negotiations occurs between therapist and patient? How do patient and therapist balance their own needs with those of the therapeutic relationship?

Design and method

The different studies of this research line have in common the use of mixed designs that combined qualitative techniques and quantitative analysis. Additionally, all the studies are of longitudinal nature since we adhere to the Dynamic Systems Theory (DST), in which the regulatory processes are conceived as complex and temporally determined phenomena.

Sample

In all the studies the sample structure is like a Russian nesting doll where we analyze relevant episodes taken from therapeutic sessions belonging to complete individual psychotherapies that have been audio and video recorded all the times.

Treatment

Psychotherapies with psychodynamic and cognitive focus in a context of outpatient treatment. The therapists males and females with more than five years of practical professional experience.

Results

-Verbal dimension of regulation: We have identified three discursive positions applicable to patients and two discursive positions for therapists. The triadic model in patients includes a meta-position role that could keep the alliance and therapeutic work.

-Non verbal dimension of regulation: We have established differences in the type of vocal qualities and facial gestures that patients and therapists use in their interactions, as well as, the associations of these differences with the interactional scenario within which they occur (change and rupture episodes).

-Characterization of the brain activity of patient and therapist: We have advanced in the development of an observation device and analytic method of the neurodynamic of the psychotherapeutic interaction.

Evaluation

This is an ongoing research line in a developing stage. Thus it limitations have to do with the different levels of advance of each subproject. In a whole its different studies are contributing to develop an emergent and multidimensional theory of the regulatory processes in the psychotherapeutic interaction.

Contact

Claudio Martínez Guzmán

Email: claudio.5martinez@mail.udp.cl

Analysis of depressive patients’ verbal expressions throughout the psychotherapeutic process - Chilean Millennium Nucleus: “Psychological intervention and change in depression”. Process research 2

Valdés, N. (2012). Analysis of verbal emotional expression in change episodes and throughout the psychotherapeutic process: Main communicative patterns used to work on emotional contents. Clínica y Salud, 23, 153-179.
Valdés, N., Krause, M., Tomicic, A., & Espinosa, D. (2012). Expresión emocional verbal durante episodios de cambio: análisis de los patrones comunicacionales utilizados por pacientes y terapeutas para trabajar contenidos emocionales [Verbal emotional expressions during Change Episodes: analysis of the communicative patterns used by both patients and therapists for working emotional contents]. Revista Argentina de Clínica Psicológica, 21, 217-246.

Background

A person's speech makes it possible to identify significant indicators which reflect certain characteristics of his/her personality organization, but also can vary depending on the relevance of specific moments of the session and the symptoms type. The work of contents associated with the patient's emotional experience during the conversation involves 3 communicative patterns (CPs) used to work on emotional content during change episodes: affective exploration, attunement, and resignification. Simultaneously, underlying cognitive processes during the therapy show a specific effect in breaking the link between affect and cognition in depressed patients, so that negative mood induction is less likely to reactivate negative beliefs and assumptions

Methods/Design

Therapeutic outcome was estimated using the Outcome Questionnaire (OQ-45.2). Both patients displayed a significant degree of change during the therapy, even though Patient A started below the cut-off score and Patient B above it. But also, both therapies displayed a positive evolution from the point of view of Generic Change Indicators (GCI), considering the number of change moments during the session (A=14, B=24), but especially due to their level in the hierarchy of indicators. The Therapeutic Activity Coding System (TACS-1.0) was used for manually coding patients' and therapists' verbalizations in each speaking turn segment during Change and Stuck Episodes. The words uttered by patients and therapists during their speaking turns in CEs and SEs were analyzed using the Spanish version of the Linguistic Inquiry and Word Count (LIWC). Each speech segment text was analyzed to identify words referencing three cognitive mechanisms: (a) cause: words reflecting the presence of a basic cognitive skill involving the speaker's attempts to explain something through an underlying logical pattern to connect the reasons behind certain phenomena or processes and their effects; (b) insight: words revealing the speaker's increased awareness or deeper understanding of the central aspects of the meaning ascribed to a certain content previously inaccessible but now experienced as novel; (c) tentativeness: words showing the speaker's consideration of different alternative meanings for certain contents; and (d) certainty: words revealing the speaker's increased assurance about something that he/she regards as true and which he/she does not doubt.

Treatment

Two short weekly individual psychodynamic therapies conducted by male psychoanalysts with a vast clinical experience, were analyzed. Both patients were female and had a similar reason for seeking help, and gave their informed consent to participate in the present study. All sessions in both therapies were included (N=39), during which 38 change episodes were identified, delimited, transcribed, and analyzed (A=14, B=24).

First Results

The analysis of the behavior of Communicative Patterns (CPs) throughout the therapeutic process, regardless of the participant's role, revealed an association between the Communicative Patterns (CPs) used to work on emotional contents during Change Episodes and the therapeutic phase, which  means that there was a larger proportion of Affective Explorations during the initial phase of the therapeutic process and a larger proportion of Affective Resignifications during its final phase. No associations were observed between the Affective Attunement displayed and the phase of the therapy. The patients' Affective Explorations during the initial phase displayed more words reflecting both cause and tentative than in the middle phase, while patients performed a larger proportion of Affective Resignifications during the final phase, in comparison with the initial phase. No differences were observed between the initial and the middle phases, as well as between the middle and the final phases in terms of Affective Resignifications with words revealing insight. However, in comparison with the initial phase, the following was observed: (a) words reflecting cause were more frequent during the middle phase; (b) words reflecting tentative were more frequent during the middle phase; and (c) words reflecting certainty were more frequent during the middle phase.

Discussion

Therefore, CPs are a relevant element in the psychotherapeutic process, because they make it possible to characterize the verbalizations of patients and therapists during therapeutic dialog. The study confirmed the notion that meaning is not something static contained in the words that a person uses, but a product of the way in which words are employed to regulate communication. This is why patients' and therapists' verbalizations were analyzed in terms of the semantic contents present during their use of Communicative Patterns, that is, considering the context in which such verbalizations were performed.

Contact

Nelson Valdés

Email: nvaldes@uc.cl

Patients´perception about termination in psychoanalytic treatments: A qualitative research study

Olivera, J., Braun, M., Gómez Penedo, J. M., & Roussos, A. (2013). A qualitative investigation of former clients’ perception of change, reasons for consultation, therapeutic relationship, and termination. Psychotherapy, 50(4), 505–516.

Abstract

From a sample of 50 former psychotherapy patients from Buenos Aires, Argentina; 16 participants identified the psychotherapy process as psychoanalysis. Those16 cases have been analyzed, in terms of how they experienced the termination process using a grounded theory approach. Results show that most therapies came to an end when the patient´s decided it, and half of the participants reported that their therapist didn´t agree with termination. Those patients whose termination has been agreed referred more satisfaction with the therapeutic process than those who didn´t.  (lo taché porque aparentemente no se require abstract)

Aims and rationale of the study

The aim of this study is to describe how private-practice patients in Buenos Aires, Argentina, have experienced the termination of psychoanalytic psychotherapy. Psychoanalytic authors agree that termination is a critical phase of treatment (Shane, 2009; Zilberstein, 2008). Premature termination is one of the most salient problems psychotherapy portrays (Nuetzel & Larsen, 2012; Swift & Callahan, 2011) and patient-initiated premature termination poses many problems both for patients and therapists (Ogrodniczuk, Joyce, & Piper, 2005). It is necessary to continue analyzing how termination takes place in real psychoanalytic treatments and how psychoanalysts may facilitate the positive resolution of therapy.

Although there are studies about patient´s perspective of termination in other countries (eg: Hynan, 1990; Knox et al., 2011; Roe, Dekel, Harel, Fennig, & Fennig, 2006), the experience of therapy in different cultures may vary. In a cross-cultural study Jock et al. (2013) found “great many and noteworthy” differences between former patients experience of therapy in Argentina and the United States (Jock et al., 2013).

Methods

Subjects were 16 former psychoanalytic psychotherapy private practice patients. Semistructured qualitative face-to-face interviews were conducted. A first open ended question: “Tell me about your therapeutic experience” allowed participants to talk freely, afterwards specific questions about termination and other significant psychotherapeutic variables were asked in order to assess the most relevant aspects of the study. Also, patients were asked to rate their therapeutic process (in a scale from 1 to 10, ten being totally satisfied). To analyze the interviews, researchers conducted a qualitative approach, based on CQR (Hill et al., 2005) and described in a former article (Olivera, Braun, Gómez Penedo, & Roussos, 2013).

Results

The majority of terminations were proposed by patients (14; 87.5%); while only two therapists initiated the termination process. Only three patients (18.75%) reported having set goals with their therapist at the beginning of therapy and, likewise, three patients (18.75%)reported having discussed therapy length with the therapist. Half of the sample (eight patients; 50.0%) indicated having agreed on termination with their therapist (agreement group). Agreement on termination included the two cases in which therapists proposed termination and six cases where patients brought the issue to therapy and their therapist agreed on termination. The other half of the sample, reported either to have dropped out or to have met with opposition from their therapist when proposing termination (disagreement group). These two halves will be referred to as “agreement/disagreement” groups.  Reasons for termination were varied and included both positive reasons, such as goal accomplishment; and negative reasons: lack of new topics; difficulties in the therapeutic relationship; and not perceiving new changes, among others.  All participants gave more than one reason for termination; typically the agreement group reported more positive reasons, while the disagreement patients reported more negative reasons for termination.

Although all patients expressed having changed due to therapy, patients with agreement on termination gave better scores of satisfaction (M=8.25; SD=.46) than the disagreement group (M=6.65; SD=1.6). Also, patients valued those therapists that proposed termination and/or referred that they would have liked their therapist to be more active by proposing termination.

Discussion

Most of our findings go in line with prior research in the area given that termination is more often proposed by patients than therapists (Olivera et al., 2013); positive terminations are related to good outcome and satisfaction with the therapy (Knox et al., 2011; Roe, Dekel, Harel, & Fennig, 2006) and motives for termination can be grouped in “positive” and “negative or conflictive” (Renk & Dinger, 2002). The unique value of this study is that it identifies a trend in psychoanalytic treatments in Buenos Aires in which most therapists do not talk about goals, length or termination of the therapeutic process and wait for the patients to address the issue. Whether they can agree with their patient about termination or not, will have an impact on the patient´s satisfaction with therapy and how the whole process will be remembered.

Limitations

The most salient limits of this study are that it has a small and nonrepresentative sample; it is based on retrospective recall; and there is no information about the therapists´ aside from what patients said. Nevertheless, this kind of research opens the window to how patients experience their termination and what they value most from the psychoanalytic therapy. It is of major importance to continue in this line of work in order to improve the psychoanalytic practice.

Contact

Email: julieta.olivera@comunidad.ub.edu.ar

Zabala 1857, Office 15 Floor 6, Buenos Aires, Argentina

Changes in object relations following intensive psychoanalytically oriented inpatient treatment

Porcerelli, J.H., Shahar, G., Blatt, S.J., Ford, R.Q., Mezza, J.A., Greenlee, L.M. (2005). Changes in object relations following intensive psychoanalytically oriented inpatient treatment. Abstracts of the 2005 Poster Session of the American Psychoanalytic Association Winter Meeting: Journal of the American Psychoanalytic Association, 53,1323-1325.

Summary

Considerable advances have been made in recent years in the assessment of mental representations. One of the most reliable and valid measures of mental representations is the Social Cognition and Object Relations Scale (Westen et al. 1990). The present study used data from the Riggs-Yale Project (Blatt and Ford 1994) to assess changes in mental representations following intensive inpatient psychoanalytically oriented treatment of severely disturbed, treatment-resistant patients.

Participants and Procedures

The study included 84 patients (mean age = 21). Patients received, on average, 1.5 years of psychoanalytically oriented treatment and had undergone psychological testing at admission and at the end of the study period. Most patients were at least middle-class, with at least average IQs. Approximately 30% were diagnosed with a DSM-III psychotic condition. Object relations were coded from six TAT cards (1, 5, 12 M, 13 MF, 14, 15).

The Social Cognition and Object Relations Scale (SCORS) includes four dimensions of object relations, each scored on a 5-point scale with scores of 5 being healthy. Complexity of Representations (CR) assesses degree of differentiation, integration and complexity. Affect-tone of Relationships (AT) assesses malevolence (vs. benevolence) of relationships. Capacity for Emotional Investment (EI) assesses the degree of need-gratifying vs. mutual relatedness. Understanding Social Causality (SC) assesses the degree to which social attributions are logical, accurate, and psychologically minded.

Discussion

Significant changes in object relations were demonstrated following psychoanalytically oriented inpatient treatment. Following treatment, descriptions of relationships were less malevolent, idiosyncratic, and illogical and showed more mutuality, complexity, and psychological mindedness. Overall, these results suggest structural changes could occur in a population of severely disturbed, treatment-resistant patients following intensive psychoanalytically oriented inpatient treatment.

Contact

John H. Porcerelli, PhD, ABPP.

Professor Director of Behavioral Medicine  Director of Clinical Faculty Development Department of Family Medicine & Public Health Sciences Wayne State University School of Medicine

Email:  jporcer@med.wayne.edu

Dyadic affective interactive patterns in the intake interview as a predictor of outcome

Rasting, M., Brosig, B., Beutel, M.E., (2005) Alexithymic characteristics and patient-therapist-interaction: a video-analysis of facial affect display. Psychopathology, 38, 105-111.
Rasting, M. & Beutel, M. E. (2005). Dyadic affective interactive patterns in the intake interview as a predictor of outcome. Psychotherapy Research, 15, 188-198.

Summary

The study aimed at testing predictions regarding the relationship between affective display and feeling states and between affective interaction patterns and clinical outcomes. The issues of this study were: (1) How do affect displays of patients and therapists differ in the intake interview? (2) How are affect displays of patients and therapists related to each other’s affect displays and respective feeling states? (3) Are specific dyadic interaction patterns predictive for the outcome of inpatient psychotherapy? (4) Are there indicators of higher affective involvement of the therapist in the unsuccessful dyads?

We assumed that facial affect displays could serve as indicators of patients’ neurotic relationship offers and therapists’ affective involvement in these interactive patterns in a clinical situation. Facial affect display would be primarily used in its symbolic and relationship regulating function. Therefore, we did not expect a close overall correspondence between feeling states and facial affective display. However, we assumed that hedonic facial affective display might have a regulating effect on the feeling state of the interaction partner. With respect to therapeutic outcome, we hypothesized that unsuccessful dyads were characterized by high involvement of the therapist in reference to reported feeling states and facial affective display. In these dyads, we expected a reciprocal facial lead affect.

For the purpose of the study, we recruited ten ‘‘successful’’ and ten ‘‘unsuccessful’’ patients from an inpatient psychotherapy ward. Over a period of 12 months, each patient’s intake and discharge interviews with the two therapists participating in the study were videotaped. According to our hypothesis, we found a strong relationship between dyadic facial affective patterns and outcome of psychotherapy. Reciprocal dyadic lead affect was related to a less favorable outcome. On the basis of the dyadic lead affect (reciprocal or nonreciprocal), 75% of the patients could be classified correctly as being part of the successful or the unsuccessful group. These findings also support the more general hypothesis that relationship patterns between patients and therapists emerge in a very early phase of treatment and have a critical impact on the course and outcome of treatment. Consensual communication, as indicated by reciprocal lead affect, may restrict the potentialities of working through neurotic conflicts in the psychotherapeutic relationship and limit corrective emotional experiences. Especially hedonic facial affects have a high probability of being reciprocated because almost 50% of the dyads with reciprocal lead affect showed a hedonic dyadic lead affect (happiness, social smile).

Contact

Prof. Manfred E. Beutel

Dept. of Psychosomatic Medicine and Psychotherapy, University Medicine Mainz, Untere Zahlbacher Str. 8, 55131 Mainz, Germany

Email: E-Mail: Manfred.Beutel@unimedizin-mainz.de

Patient and therapist perspective on therapeutic action in psychoanalysis and psychoanalytic psychotherapy: Helpful and hindering factors

Lilliengren, P., & Werbart, A. (2010). Therapists’ view of therapeutic action in psychoanalytic psychotherapy with young adults. Psychotherapy: Theory, Research, Practice, Training, 47, 570–585.
Palmstierna, V., & Werbart, A. (2013). Successful psychotherapies with young adults: An explorative study of the participants’ views. Psychoanalytic Psychotherapy, 27, 21–40.
Werbart, A., & Levander, S. (2006). Two sets of private theories in analysands and their analysts: Utopian versus attainable cures. Psychoanalytic Psychology, 23, 108–127.
Werbart, A., & Levander, S. (2011). Vicissitudes of ideas of cure in analysands and their analysts: A longitudinal interview study. International Journal of Psychoanalysis, 92, 1455–1481.

Summary

This research program aims to explore patient and therapist views of helpful and hindering factors in psychoanalysis and psychoanalytic psychotherapy, applying rigorous qualitative methods. A series of studies was based on periodical interviews with seven analysands and their analysts (Werbart & Levander, 2006, 2011). Double sets of private theories of cure were found among analysands and their analysts. Ideas of utopian cure involved a profound transformation of the personality by way of deep regression. Ideas of an attainable and more limited cure included new ways of managing old problems and new ways of thinking and reflecting. The ongoing treatment was then seen as the ‘next-best solution’. Both parties’ mourning of the preferred but abandoned utopian theories of cure seems to be an important ingredient in the psychoanalytic process. Furthermore, the utopian fantasy of creating ‘the new person’ by means of ‘proper’ psychoanalysis or analytic training has far-reaching consequences for psychoanalytic education and supervision.

Further studies focused on young adults in psychoanalytic psychotherapy. Patients experienced as curative talking openly in the context of a safe relationship, which led to new relational experiences and expanding self-awareness. Hindering factors included difficulties “opening up,” experiencing the therapist as too passive and that something was missing in therapy. According to the therapists, the core curative factor was the development of a close, safe and trusting therapeutic relationship, while patients’ fear about close relationships emerged as the sole hindering factor from the therapists’ perspective (Lilliengren & Werbart, 2010). In a study of overcoming depression, positive changes experienced by young adult psychotherapy patients extended beyond symptom relief and included finding out how they wanted to live and forming their lives in that direction. Dissatisfied psychotherapy patients described abandonment by a therapist felt to be insufficiently flexible, a therapy lacking intensity, and links missing between therapy and everyday life. They lacked confidence in their relationship with the therapist, wanted more response from the therapist, and concluded that their therapies lacked direction. Conversely, the most successful cases described a secure therapeutic relationship where growth could take place. The patients and their therapists experienced the therapeutic work in a strikingly similar way, worked actively towards joint goals, overcame obstacles to their collaboration, explored what was painful and actively promoted the use of new skills after termination (Palmstierna & Werbart, 2013).

In a two-stage mixed-method study of clinically nonimproved patients, “Spinning One’s Wheels” emerged as a core category. The patients described the therapeutic relationship as distanced and artificial. While they saw active components in therapy and their own activities in life as beneficial, therapy itself was experienced as overly focused on problem insight and past history. The phenomenon of ongoing therapy without symptom reduction was interpreted as a product of imbalance between the three components of therapeutic alliance, with a good-enough emotional bond, but no shared understanding of goals and tasks in therapy. A number of current studies further examine patients’ view of the therapeutic relationship three years post termination, as well as the therapists’ view of psychotherapy processes in longitudinally clinically significant improved cases, and in cases of non-improvement in psychoanalytic psychotherapy.

Contact

Andrzej Werbart

Professor, Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden.

Email: andrzej.werbart@psychology.su.se

Website: http://www.psychology.su.se/staff/anwe

Changes in mental representations and personality configurations after psychoanalysis and psychoanalytic psychotherapy

Werbart, A., in collaboration with Grünbaum, C., Jonasson, B., Kempe, H., Kusz, M., Linde, S., Lundén O’Nils, K., Sjövall, P., Svenson, M., Theve, C., Ulin, L., & Öhlin, A. (2011). Changes in the representations of mother and father among young adults in psychoanalytic psychotherapy. Psychoanalytic Psychology, 28, 95–116.

Werbart, A., & Forsström, D. (2014). Changes in anaclitic–introjective personality dimensions, outcomes, and psychoanalytic technique: A multi-case study. Psychoanalytic Psychotherapy 28,397–410, doi:10.1080/02668734.2014.964295.

Arvidsson, D., Sikström, S., & Werbart, A. (2011). Changes in self- and object representations following psychotherapy measured by a theory-free, computational, semantic space method. Psychotherapy Research, 21, 430–446.

Summary

Treatment goals in psychoanalysis often include changes in underlying dynamic mental structures, such as self- and object representations, or personality configurations. The aim of this ongoing research program is to study changes in self- and object representations, and in the anaclitic-introjective personality configuration following psychoanalysis and long-term psychoanalytic psychotherapy. Furthermore, we investigate personality related responses to the psychoanalytic process, as well as patients’ experiences of changes in dynamic mental structure. This research program combines quantitative and qualitative methods, and integrates theory-neutral and empirically-driven, inductive approach with a theory-driven, deductive approach.

Twenty-five women and 16 men from the Young Adult Psychotherapy Project (YAPP) were interviewed according to Sidney Blatt’s unstructured Object Relations Inventory prior to psychoanalytic psychotherapy, at termination and at the 1.5-year follow-up. Typologies of representations of self, mother and father were constructed by means of ideal-type analysis for male and female patients separately, and the changes were studied from prior to psychotherapy through long-term follow-up. The clusters of self-representations could be depicted on a two-dimensional space with the axis Relatedness (anaclitic personality style) – Self-definition (introjective personality style) and the axis Integration – Non-integration. The most common descriptions of the parent were the emotionally or physically absent parent, and the parent with his or her own problems. In most cases, the descriptions of the parent changed over time. There was a movement towards more integrated self-descriptions and a better balance between relatedness and self-definition. However, most of the parental representations were negative. There were important improvements in the quality of the self- and parental descriptions, and the changes continued after termination of psychotherapy (Werbart et al., 2011; Werbart, Brusell, & Widholm, 2013). These findings were further corroborated in a study applying a theory-neutral, computational and data-driven method for assessing changes in semantic content of self- and object representations (Latent Thematic Analysis). Young adults in psychotherapy are compared with an age-matched, non-clinical sample at three time points. In the psychotherapy group, all representations changed from baseline to follow-up, whereas no comparable changes could be observed in the comparison group. The semantic space method supported the hypothesis that long-term psychoanalytic psychotherapy contributes to sustained change of affective-cognitive schemas of self and others (Arvidsson, Sikström, & Werbart, 2011).

In a study of personality related responses to the psychoanalytic process, 7 analysands and their analysts were repeatedly interviewed at the beginning, during and after the analysis about the analysands’ problems and helpful/hindering factors in the analytic process. The analysands were categorized as initially anaclitic or introjective according to Blatt’s personality model. The introjective group expected improved emotional control and ability to regulate interpersonal distance in addition to better understanding the roots of their problems. The anaclitic group believed that the analyst’s strength and empathy would help them handle their need of support and love. The introjective group saw their own problems as the main hindrance in analysis but also directed critique to the analyst as a person. Their analysts’ experienced that the analysands wanted to do the work by themselves and were difficult to engage in the analytic process. The analysands in the anaclitic group were more occupied by hindrances in the psychoanalytic frame and attitude. Their analysts, on the other hand, sometimes found the work difficult and frustrating. These findings underline the importance of being aware of personality differences in analysands’ response to specific dimensions of the analytic process (Levander & Werbart, 2012).

Changes in the anaclitic-introjective personality configuration were investigated in relation to outcomes in 14 cases of publicly financed psychoanalysis. The method of prototype matching was adapted for personality assessment and multiple outcome measures were applied. We found a moderate increase in the other polarity while still maintaining the basic character structure with which the patients started treatment. Both groups developed more mature and integrated expressions of relatedness and self-definition. For the anaclitic cases symptom reduction was accompanied by more mature integration of anaclitic and introjective personality dimensions, while the introjective cases could show symptom reduction without such improvement. This could indicate that sustainable change in latent mental structures is more difficult to achieve in introjective than in anaclitic patients. Both groups described their experienced changes in terms of complementary personality orientation, but the introjective group described more benefits from psychoanalysis. Several patients expressed their ambivalence to these changes and a feeling of loss of their previous personality orientation. The patients’ view of their analysts and the analytic method were congruent with the patients’ primary focus on relationship or self-definition. In order to reactivate developmental processes in psychoanalysis, the psychoanalytic technique has to be adjusted to the anaclitic and introjective patients’ different needs and defenses.

A number of current studies further examine the relationship between patient characteristics (gender, personality configurations), psychotherapy process, changes in dynamic mental structures, and the participants’ subjective experiences of change processes.

Contact

Prof. Andrzej Werbart

Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden.

Email: andrzej.werbart@psychology.su.se

Website: http://www.psychology.su.se/staff/anwe

The Inventory of Personality Organization (IPO): Its validity in Argentine populations through non-clinical and clinical samples comparision groups

Persano, H.L. (2002): Inventario de organización de la personalidad (IPO), Spanish translation. Mental Health Department, School of Medicine, Univeristy of Buenos Aires, 2002.
Quiroga, S.; Castro Solano, A.; Fontao, M. I. (2003): La evaluación de la estructura de la personalidad: Adaptación argentina del inventario de organización de la personalidad (IPO). Subjetividad y procesos cognitivos, 3, 188-219.
Silva de Oliveira, S.E.; Ruschel Bandeira, D. (2011): Linguistic and cultural adaptation of the Inventory of Personality Organization (IPO) for the Brazilian culture. J. Depress Anxiety, 1:1. http://dx.doi.org/10.4172/2167-1044.1000105.

Aim

The aim of this research is to validate the validity of the IPO, 83 items, in Argentine populations.

The IPO is an instrument which was designed to operationalize Otto Kernberg’s ideas concerning borderline personality organization (BPO) diagnosis (Lezenweger, M. et al. 2001). The IPO is a multidimensional research tool which is used to differentiate dimensions of personality organization. For Otto Kernberg, primitive defenses, identity diffusion and distortions in the relation with reality are common disturbances in BPO, and they became the three specific variables used for the structural diagnosis (Kernberg, O, 1984).

The IPO was validated previously into Spanish but onto 155 items format (Avila Espada, A. et al. 2000), and this 155 items format was also adapted into an Argentinean version (Quiroga, S. et al. 2003). As a consequence of several reviews that took place, in 2001 the IPO was modified into a shorter version, with an 83-item questionnaire. It is still used to explore five main dimensions of the psychic level of functioning: primitive defenses (PD), identity diffusion (ID), reality testing (RT), aggression (A) and moral values (MV).The IPO 83 items was translated into Spanish by Humberto Persano under Otto Kernberg supervision (Persano, H. 2002) under IPA grant for a broader research on defense mechanisms.

The IPO was validated and adapted in different countries: Chilean version (Ben-Dov, P. et al. 2002), Dutch version (Berghuis, J. et al. 2009), Japanese version (Brazilian version (Silva de Oliveira, S.E. et al. 2011), German version (Dammann, G et al. 2012) and also there are European Portuguese and Italian versions unpublished.

For validation purpose in Argentine a comparison study was designed in order to test the strength of the IPO in differentiating between clinical and non-clinical samples.

Methods

The five dimensions of the IPO were tested in this trial to compare two groups: non-clinical and clinical sample. The aim of the present study was to apply the IPO on a large sample of university students. The IPO was administrated to students from different universities and regions of Argentine, and to compare this non-clinical sample with a BPD clinical sample. The clinical sample was recruited from both inpatients and outpatients sample which fulfill BPD diagnosis according to DSM-IV TR. The aim of this research design was developed to validate the IPO 83 items in Argentine. IPO 2001 was administrated to non-clinical sample in a voluntary and anonymous way. Also it was applied to a clinical sample after approval of The Ethical Independent Committee of The Hospital Colonia Domingo Cabred, where the clinical sample was recruited.

The subjects involved in the non-clinical sample were recruited from both public and private universities from different regions of the country (n=1068) and it was carried out on 2003-2004; distribution gender (66,8% female and 33,2% male); age median 22, SD (5,2). The clinical sample was recruited from both inpatients and outpatients sample at the  Colonia Domingo Cabred Hospital in Buenos Aires, which fulfill BPD diagnosis according to DSM-IV TR (n= 169); distribution gender (female, 60,4%, male 39,6%), age median 28, SD (10,8).

Statistical comparison was made using non parametric tests. Statistical differences were confirmed through Mann-Whitney Test, Two-Sample Kolmogorov-Smirnov Test and Kruskal-Wallis Test for independent variables.

Results

Level of personality organization was significant different in both samples through five variables studied in this research. Primitive defense mechanisms (PD, p<0.001), identity diffusion phenomena (ID, p<0.001), impairment in reality testing (RT, p<0.001), aggression (A, p<0.001) and disturbances in moral values (MV, p<0.001) are more present in BPD patients recruited from clinical sample than in non-clinical sample. The statistical analysis through three nonparametric tests mentioned above has shown that all five variables represent significant different values in both samples. Another interesting result is no gender differences were found both in clinical and non-clinical samples.

Conclusions

The IPO self report format interview would help interviewers to explore these three dimensions through the PD, ID and reality testing (RT) items. It is generally accepted that a lower level of defense mechanisms is present in severe psychopathology, as well as the identity diffusion phenomena. Disturbances in reality testing expressed by difficulties in clearly differentiating self from non-self representations are common in the borderline realm, as well are the oscillating representations of the social common sense of reality. It is very common to observe that borderline patients often behave under the aggression domain: impulsivity, self-injuries and suicidal attempts and gestures. These symptoms are explored by the aggression (A) subscale of the IPO. It is also very well known that these patients have disturbances in the integration of the superego structure and the IPO format interview can reveal these characteristics through the moral values (MV) subscale.

Although the IPO is not used as a clinical diagnostic tool, it would allow experts to distinguish between severe psychopathology and healthy people, while exploring these three main subscales (PD, ID, RT) of the IPO which reveal the structure of the psychic function, and the others (A and MV) subscales reveal aggression control behavior and superego structure.

Contact

Persano, Humberto Lorenzo (Argentine Psychoanalytic Association (APA) & University of Buenos Aires  (UBA); Gutnisky, David (UBA); Ventura, Adrian (APA- UBA); García Lizziero, Ezequiel (UBA); Chertcoff, Lisandro (UBA).

E-mail: hpersano@gmail.com

The patient-therapist interaction and the recognition of affects during the process of psychodynamic psychotherapy for depression.

Ahola P, Valkonen-Korhonen M, Tolmunen T, Joensuu M, Lehto SM, Saarinen PI, Tiihonen J, Lehtonen J.  (2011). The patient-therapist interaction and the recognition of affects during the process of psychodynamic psychotherapy for depression. American Journal of Psychotherapy, 65, 355-379, 2011.

Method

The perceptions of patients (n=25) and their therapists of the process of psychodynamic psychotherapy for depression were assessed during the first treatment year using 23 scales: Formation of the treatment contract, emergence of a rational treatment alliance, recognition of depression and hopelessness within treatment setting, emergence of affective relationship between the patient and the therapist, current self experience, intimate object relationships (state and dealing with them), social object relationships (state and dealing with them), dealing with aggressions, work and other occupational problems (state and dealing with them), reactivation of negative and withdrawn affects within the therapeutic relationship, object ambivalence (positive and negative affects and thoughts), working with depressive  mental contents and hopelessness, experiences of being understood and mirrored in therapy, recognition of changes therapy has made possible.       

Findings

Patients and therapists independently evaluated the impact of these subjects on the therapeutic experience of the patients during the one-year long treatment period. The estimations by the patients and therapists were concordant in the majority of the scales,reflecting mutual tuning and working alliance within the therapeutic couple. The roles of affects and frustrating subjects in the treatment relationship were , however, evaluated  significantly differently by the patients and therapists. The results highlight  the importance of working on the expression of affects, especially with those of aggressive contents in the psychotherapy of depression.

The validation of the findings by factor analysis in relation to the treatment outcome is in progress.

Contact

Prof. J. Lehtonen

University of Eastern Finland and the University Hospital of Kuopio

Departments of Psychiatry, Clinical Physiology and Forensic Psychiatry, Niuvanniemi Hospital

National Institute of Health and Welfare, Helsinki

E-mail: johannes.lehtonen@fimnet.fi

Psychological intervention and change in depression. Depression, a complex phenomenon: Understanding the syndrome and treatment response

Background

Investigators from different theoretical positions have discussed two major types of experiences that tinge psychopathology as depression: (1) disruptions of gratifying interpersonal relationships (for example, object loss), and (2) disruptions of an effective and essentially positive sense of self (for example, failure). From a psychoanalytic cognitive-developmental standpoint some depressed patients show a self-criticism personality trait (introjective) meanwhile others have a tendency to show a dependence personality trait (anaclitic).

Subprojects:

-Adult attachment, social network and personality traits: their relation with depression.

-Alliance evolution in two types of depression (anaclitic/introjective)

Research questions

Anaclitic and introjective depression are the key elements of this research, from here, questions arise:- Can we describe thoroughly both types of depression (in terms of initial alliance, expectations, attachment, social support, etc.)?. How is the evolution of process variables for each type?

Design and method

When applying psychological assistance in a private health center, participants are invited to be part of this study. Those who agree to participate, signed informed consent and completed some questionnaires (A) prior to the first psychotherapy interview, and during psychotherapy (B).

Sample:  99 patients have been included so far in this study that is still in progress.

Treatment: Therapies are held in a private outpatient clinic that delivers brief psychotherapies (8-12 sessions). Psychiatrists have diagnosed all patients.

Treatment is as usual in this natural setting, no manualization.

Measures

Depressive symptoms: The Beck Depression Inventory (BDI-I-A, Beck et al., 1961)

Depressive Experience Questionnaire (DEQ, Blatt, D’Afflitti, & Quinlan, 1976)

Attachment in couples relationships: the Experience in Close Relationships Scale, (ECR, Brennan, Clark & Shaver, 1998)

Social Support Questionnaire (SSQ-6, Sarason, Sarason, Shearin & Pierce, 1987)

Psychotherapeutic Expectative (PATHEV, Schulte, 2005)

(A and B) Outcome Questionnaire (OQ-45.2, Lambert et al., 1996)

Cultural Variables (CMVC

Session Evaluation Questionnaire (SEQ, Stiles, 1980)

Working Alliance Inventory (WAI, Horvath & Greenberg, 1986)

Results

99 patients (77.8% women). Age X:43.12 years (DS:13.43). 50.0% married, 35.7% single, 4.1% widowed and 10.2% divorced. 36.7% have university studies, 22.4% have completed high school, 22.4% have technical studies.

BDI, 39.2% Severe depression, 32.0% Moderate, 21.6% Low and 7.2% Minimal depression. Types of depression (measured by DEQ), 32.9% Mixed depression, 17.6% Anaclitic, 17.6% Introjective and 31.8% Uncategorized.

In a sub-sample of 70 the results showed that both maladaptative attachment styles (anxious and avoidance) relates with self-criticism personality dimension. Also when looking at social networks, only avoidance attachment style relates inversely with this variable – in relation with size and satisfaction of the social network-.

Two mediational analyses were made; both models showed that self-criticism mediates the relation between the variables of attachment (anxiety and avoidance) and depressive symptomatology, not the same with dependency level. This means that patients that presents high levels of anxiety or avoidance have higher self-criticism in the interactions and that this relates with higher depressive symptoms.

The moderation analysis showed that when the level of satisfaction with the social network is low and the anxiety attachment level is high, meanwhile the avoidance increases, depressive symptoms increases as well.

Evaluation

This study is still in progress and only preliminary results arise. One main limitation is that the study relies on depressed patients,; later specification a non clinical sample must be addressed.

Contact

Paula Dagnino, Ph.D

Universidad Alberto Hurtado

Facultad de Psicología

Almirante Barroso 10, Stgo, Chile

pdagnino@uahurtado.cl

Email: padagnin@uc.cl

Psychological intervention and change in depression: Exploring depressive experiences

Research questions

-Which are the structural vulnerabilities of anaclitic and introjective depressive experiences?

-Which are the structural resources of anaclitic and introjective depressive experiences?

-What about the evolution of process variables for each type of depressive experience, considering their vulnerabilities?

Design and method

Clinical sample: To 150 patients OPD-SQ will be applied, together with BDI and DEQ at the beginning of psychotherapy. Through the process OQ and WAI are applied. At the end of psychotherapy OPD-SQ and BDI are applied again.

Non clinical sample: 150 people without depression (BDI) will answer OPD-SQ and DEQ.

Treatment is as usual in different outpatient clinics. (natural settings)

Measures

Operationalized Psychodynamic Diagnosis- Structure Questionnaire (OPD-SQ, Ehrenthal, Dinger, Horsch, Komo-Lang, Klinkerfug, Grande, & Schauenburg, 2012).

Depressive symptoms: The Beck Depression Inventory (BDI-I-A, Beck et al., 1961)

Depressive Experience Questionnaire (DEQ, Blatt, D’Afflitti, & Quinlan, 1976)

Outcome Questionnaire (OQ-45.2, Lambert et al., 1996)

Working Alliance Inventory (WAI, Horvath & Greenberg, 1986)

Results

The study is just starting, so there are no results so far. The sample is being recluted and some questionnaires are being digitalized to further analysis.

Contact

Paula Dagnino, Ph.D

Universidad Alberto Hurtado

Facultad de Psicología

Almirante Barroso 10, Stgo, Chile

pdagnino@uahurtado.cl

Email: padagnin@uc.cl

Psychological intervention and change in depression: Failure in psychotherapy from the experience of patients diagnosed with depression. A qualitative comparative study.

Background

Between 5% and 10% of patients get worse at the end of psychotherapy. Dropout rates in psychotherapy are estimated at 46.86%. However, there is a publication bias, in the sense that successful therapies are over-represented). Consequently, the failure of therapies has not received enough attention in literature. Additionally, the perspective of patients regarding failure of therapy has not been sufficiently considered. The aim of this study is to capture the meanings of negative evaluation of the psychotherapy, from the experience of Chilean patients diagnosed with depression, and compare it with patients that had successful experiences.

Research questions

What are the meanings associated with a negative evaluation of the psychotherapy in Chilean patients diagnosed with depression from their experience in a psychotherapeutic process?

1. Explore the meanings associated with a negative evaluation of psychotherapy from the experience of Chilean patients diagnosed with depression, compared with patients that had successful experiences.

2. Identify causes attributed to a negative evaluation of psychotherapy from the experience of Chilean patients diagnosed with depression, compared with patients that had successful experiences.

3. Identify possible consequences of negative evaluation in psychotherapy, compared with patients that had successful experiences.

Design and method

Qualitative methodology. A descriptive-analytic relational design. Data collection included follow-up semi-structured interviews performed with the clients after finished or dropped-out psychotherapy. Data analysis was carried our according to Grounded Theory procedures, including open, axial and selective coding.

Sample: The study included patients diagnosed with depression and treated at semi-funded institution of mental health (6, 8 or 12 session pre-assigned, depending severity).

Sample: 40 patients follow up interviews.

Treatment: This study includes non-manualized brief psychotherapies aimed at the resolution of depressive symptoms, independent of psychotherapist theoretical model. 6, 8 or 12 psychotherapy session pre-assigned, depending severity, with the flexibility of extend a few sessions, case by case.

Measures: Semi-structured and narrative interview.

Results

Results allowed identify the criteria used by patients to determine when a psychotherapeutic process is unsuccessful and compare it with a successful process. Furthermore, they permit to develop a comprehensive model of negative evaluation of the psychotherapy from the patient´s point of view.

In summary

- It was possible to distinguish 3 groups of patients in relation to the overall evaluation of psychotherapy from their subjective experience: 20 patients with positive evaluation, 13 patients with mixed, and 7 patients with negative evaluation.

- Patients are able to assess their differential effects attribute psychotherapy, other treatments or life situations.

- Patients did not only consider the lack of symptomatic relief when evaluating negatively their psychotherapy.  Factors that stood out were:

- Distrust and Misunderstanding

- Absence of Focus working

- Didn't have the experience of "Change in oneself" as opposed to successful cases

- Didn't have a "transforming psychotherapy relationship" as opposed to some successful cases

- Patients with negative and mixed evaluation, didn´t talk directly about their bad feelings to the therapist. They felt that wasn´t appropriate.

Conclusion

Even in many very brief psychotherapies(focused on symptomatic relief) patients feel that one of the most important factors of psychic change is the "transformative relationship" with the psychotherapist, relationship contrary to dysfunctional depressive pattern. 

Evaluation

This study is in progress. Still need to perform qualitative analysis. Later be incorporated into the analysis further comparison with quantitative instruments such as the BDI and OQ45.2, and therapist´s interviews.

Some limitations

- The study provides a specific frame of brief psychotherapies aimed at the resolution of depressive symptoms independent of the theoretical model of the psychotherapist.

- Are not manualized psychotherapies.

Contact

Nicolás Suárez Delucchi, Phd(c)

Email: nsuarez@uc.cl, nicolasuarez@gmail.com

 Facial affective relationship offers of patients with panic disorders

Benecke , C. & Krause, R. (2005). Facial  affective relationship offers of patients with panic disorders. Psychotherapy Research, 15, 178 –187.
Benecke, C. & Krause, R. (2005). Initial affective facial behaviour and outcome satisfaction in the psychotherapy of patients with panic disorder. Zeitschrift für Psychosomatische Medizin & Psychotherapie,  51, 346-359.

Summary

The affective facial behavior of patients with anxiety-disorders and that of their psychotherapists was analyzed following specific hypothesis about the domination of dependency autonomy conflicts of these patients including an ambivalent need for a positive relationship toward a significant object and an incapacity to express negative feelings because of fear of losing this relationship. The authors investigated facial indicators of this conflict in 20 women with panic disorder in the first psychotherapy session. A preponderance of facial smile and a lack of negative affective facial signals were expected. This was not confirmed for the total sample. A cluster analysis identified two subgroups of panic patients. One group confirmed the assumptions precisely. The other did as well but only insofar as the patients smiled more often than a sample of a mixed clinical control group that excluded panic disorders. In addition, the panic patients of this cluster showed much negative affect. The patients of the two panic clusters did not differ in panic and other symptoms but did so in their descriptions of their interpersonal behavior.

Additionally the data of facial behaviour was correlated with outcome ratings at the end of the treatment. Therapists show less affective facial behaviour than panic patients; particularly, they smile less frequently. The frequency of smiling in the first session correlated negatively with outcome ratings. Therapists adapted their interactive behaviour to the relationship offers of their patients.

Contact

Prof. C. Benecke

University of Kassel

Email: benecke@uni-kassel.de

Metaphors and affect

Fabregat, M., & Krause, R. (2008). {Metaphors and affect: their interrelation in the therapeutic process}. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 54, 77-88.

This piece of research deals with the relationship between affect and its transference into language in “hidden ways” before it appears as purposefully verbalised meaning.

Design

Using videotapes of 10 fifteen-hour short -term therapies by very experienced therapists treating an unselected group of patients, facial affect and metaphoric language of the therapist and the patient as well as the temporal distance between the two were recorded.

Results

The density of metaphors was not significantly correlated with symptom reduction but with treatment satisfaction. However symptom reduction correlated significantly with the frequency of interactive metaphors used by both the therapist and the patient. It could be shown that there is an optimal time window between facial affect and metaphor production beyond the here and now, but not as a long term memory.

Contact

Prof. Dr. R. Krause

Universität Saarbrücken

Email: r.krause@mx.uni-saarland.de

Fibromyalgia, facial expression and emotional experience

Kirsch, A. & Bernardy, K. (2007). Fibromyalgia, facial expression and emotional experience. Psychopathology, 40, 203-208.

We studied the facial affective behaviour (facial expression) of female fibromyalgia (FM) inpatients which was compared to healthy woman (absence of mental/psychiatric disorder according to ICD-10). The facial affective behaviour was coded with the Emotiona Facial Action Coding System. Videotaped psychodynamic interviews of each of 15 female FM inpatients and healthy women were analyzed. The facial expression was related to gazing behaviour and emotional experience.

FM patients exhibited neither a reduction in total activity of facial expression nor in absolute frequency of primary affects compared to healthy women, who, however, in mutual gaze and eye contact showed a significantly higher proportion of “genuine joy” and a lower one of “contempt”. No congruence between the patient’s emotional experience and facial expression was found. We concluded that the absence of reduced total activity of facial expression is in contrast to the elaborate descriptions of complaints provided by the patients. Nevertheless, our analysis (amongst others) showed a lack of elements that stabilize a relationship. Especially genuine smiling stabilizes the relationship between two persons, it keeps the communication going on, which has also an impact on the countertransference of the therapist. The healthy women in our study hardly differed from the patient according to negative, distance inducing affects like anger and disgust. Contempt, however, was shown more than twice as often by the patients. Contempt is an affect that serves to abandon a relationship with another person or prevents it from establishing. Furthermore, it contains a devaluation of the interaction partner, in this case the therapist. The patient gives an impression of facial affective lifeliness and “health”, at the same time stabilizing elements do not occur, and distance inducing ones are implemented.

Contact

Prof. Dr. A. Kirsch

University of Heidelberg

Facial expression and experience of emotions in psychodynamic interviews with patients with PTSD in comparison to healthy subjects

Kirsch, A.  & Brunnhuber, S. (2007). Facial expression and experience of emotions in psychodynamic interviews with patients with PTSD in comparison to healthy subjects. Psychopathology, 40, 296-302.

The facial affective behaviour informs others of current emotions and evokes responses that shape social interactions, influences relationship satisfaction, and as we assumed, adjustment to traumatic events.

Design

We videotaped 15 clinical interviews with traumatized patients in comparison to a healthy control group (absence of mental/psychiatric disorder according to ICD-10).

Findings

As well as the FM inpatients, the traumatized did not show a reduction of overall facial expression nor a reduced frequency of facial affects in comparison to the healthy controls. The control group, however, showed significantly more “genuine joy”, the traumatized patients significantly more “anger”. We concluded that this indicates the importance of distance regulating interaction patterns of traumatized patients. Within a clinical dyadic patient-therapist setting, anger could lead to an unconscious relationship-pattern “object go away!”. In the countertransference of the therapist anger affects could enhance insufficient empathy, missing exploration of the traumatic event to the point of unconscious aversion of which the therapist has to become aware.

Contact

Prof. A. Kirsch

University of Heidelberg

Childhood-onset versus acute, adult-onset traumatized patients

Kirsch A., Krause, R.,  Spang, J.,  Sachsse U.  (2008) Childhood-onset versus acute, adult-onset traumatized patients in the light of amnestic tendencies and derealisation . Z Psychosom Med Psychother 54, 277-284

Brief Summary

This research project related facial – affective behaviour in traumatized patients to dissociation including amnestic tendencies and derealisation.

Facial affective behaviour of acute adult-onset traumatized patients versus childhood-onset traumatized patients was analyzed with the Emotional Facial Acting Coding System, an instrument for the registration of facial movements with emotional relevance.

The facial affective behaviour of the patient’s first and last EMDR sessions was compared. Childhood-onset and acute adult-onset traumatized patients showed the same amount of overall facial activity. Childhood-onset traumatized patients showed higher values of derealisation (FDS). The reduction remains constant over time. Also childhood-onset traumatized patients developed more psychic complaints and greater derealisation.

Using the same corpus of data it was investigated whether the facial affective behaviour of patients with posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) could be used to discriminate the two groups. Patients were assigned to clusters which were then compared for emotional numbing and dominant affects. In Cluster 1 the negative affects anger, contempt and disgust were dominant to the exclusion of other primary affects. Chief affects expressed in cluster 2 were disgust, social smiling and contempt. Clusters 3 displayed the full range of primary affects, with grief the most frequent. BPD as additional diagnosis was significantly more frequent in clusters 1 and 2 than in cluster 3. The finding that PTSD patients in Clusters 1 and 2 display a significantly more frequent co-morbidity with BPD than those in Clusters 3 is discussed against the background of the range of facial - expressive affects.

Relational and classical elements in psychoanalyses: An empirical study with case illustrations

Waldron, S., Scharf, R. D., Hurst, D., Firestein, S. K., & Burton, A. (2004). What happens in a psychoanalysis: A view through the lens of the Analytic Process Scales (APS). International Journal of Psychoanalysis, 85, 443–466..

Brief Summary

The first aim of this article is to report a newly developed measure of therapeutic process, the Dynamic Interaction Scales. When combined with the Analytic Process Scales (Waldron, Scharf, Crouse, et al., 2004; Waldron, Scharf, Hurst, et al., 2004), the two instruments permit a reliable and fine-grained assessment of technical and relational aspects of psychoanalytic and psychodynamic psy- chotherapeutic process. The Shedler-Westen Assessment Procedure and Psy- chological Health Index (Westen & Shedler, 1999a, 1999b; Waldron et al., 2011) permit a reliable and fine-grained assessment of the changes during treatment. The second aim is to demonstrate how combining results from these instruments permits exploring the relationships between processes and out- comes of treatment. We illustrate the utility of this approach by a demonstration project, applying the instruments to two treatments started 21 years apart. The results show different relational and classical approaches of the analysts and different outcomes. Both patients had a similar level of psychological function- ing at the outset of treatment, but one made a much more extensive recovery than the other. The difference in outcomes may reflect different patient pathol- ogy, in spite of their initial level of functioning, but it may also reflect the impact in the better outcome case of a more relational approach, combined with a more extensive use of classical analytic interventions judged to be of higher quality. We then present quantitative results applying the same instruments to 11 additional patients. Technical and relational differences are found between good and poor outcome cases in this group, similar to those found in our two demonstration cases. Ongoing evaluation of an additional 18 cases will permit further study of these differences.

Evaluation

Previous researchers on short-term or even medium-term psychotherapy outcomes have generally not found that therapists’ varying technical contributions to treatment account for much of the differences in outcomes (e.g., Norcross, 2011; Wampold, 2001). By contrast, our findings, if further confirmed in a larger sample, affirm the importance of the therapist’s contribution to benefit. We will have moved closer to confirming what most psychoanalysts have believed for a long time: that both the quality of the analyst’s relationship with the patient and the ability to provide useful verbal communications are crucial therapeutic factors. In other words, the differing emphases of relational and classical theory each have a contribution to the course of treatment that exceeds the benefit of either the relationship alone or interpretation and insight alone. And it seems clear that if, on one hand, interpretations and insights are a function of and happen in the context of a human relationship, on the other hand, a human relationship is shaped by the reciprocal understanding of the people in the relationship (Høglend et al., 2007).

Contact

Sherwood Waldron, MD

Psychoanalytic Research Consortium, 40 East 94th Street, Suite 11B, New York, NY 10128

E-mail: woodywald@earthlimk.net