Change in defense mechanisms and coping patterns during the course of 2-year-long psychotherapy and psychoanalysis for recurrent depression: a pilot study of a randomized controlled trial.

Very little research has been conducted so far to study the potential mechanisms of change in long-term active psychological treatments of recurrent depression. The present pilot randomized controlled trial aimed to determine the feasibility of studying the change process occurring in patients during the course of 2-year-long dynamic psychotherapy, psychoanalysis, and cognitive therapy, as compared with clinical management. In total, eight outpatients presenting with recurrent depression, two patients per treatment arm, were included. All patients were randomly assigned to one of the four treatment conditions. Defense mechanisms and coping patterns were assessed using validated observer-rated methodology based on transcribed, semistructured follow-along independent dynamic interviews. The results indicated that, whereas some patients in the active treatments changed on the symptomatic levels, some others remained unchanged during the course of their 2-year-long treatment. However, with regard to potential mechanisms of change in these patients, changes in defense mechanisms and coping patterns were revealed to be important processes over time in successful therapies and, to a lesser extent, in less successful treatments. No change was found either on outcome or on the process measure for the control condition, that is, clinical management. These results are discussed along with previous data comparing change in defense mechanisms and coping during the course of treatments.

One minute of grief: Emotional processing in short-term dynamic psychotherapy for adjustment disorder.

OBJECTIVE: Depth of emotional processing has shown to be related to outcome across approaches to psychotherapy. Moreover, a specific emotional sequence has been postulated and tested in several studies on experiential psychotherapy (Pascual-Leone & Greenberg, 2007). This process-outcome study aims at reproducing the sequential model of emotional processing in psychodynamic psychotherapy for adjustment disorder and linking these variables with ultimate therapeutic outcome. METHOD: In this study, 32 patients underwent short-term dynamic psychotherapy. On the basis of reliable clinical change statistics, a subgroup (n = 16) presented with good outcome and another subgroup (n = 16) had a poor outcome in the end of treatment. The strongest alliance session of each case was rated using the observer-rated system Classification of Affective Meaning States. Reliability coefficients for the measure were excellent (κ = .82). RESULTS: Using 1 min as the fine-grained unit of analysis, results showed that the experience of fundamentally adaptive grief was more common in the in-session process of patients with good outcome, compared with those with poor outcomes (χ2 = 6.56, p = .01, d = 1.23). This variable alone predicted 19% of the change in depressive symptoms as measured by the Beck Depression Inventory at the end of treatment. Moreover, sequences of the original model were supported and related to outcome. CONCLUSIONS: These results are discussed within the framework of the sequential model of emotional processing and its possible relevance for psychodynamic psychotherapy. (PsycINFO Database Record (c) 2015 APA, all rights reserved).

Individualizing exposure therapy of PTSD: the case of Caroline

In therapy for chronic posttraumatic stress disorder (PTSD), prolonged exposure (PE) to stimuli associated with an original trauma experience is considered a state-of-the-art treatment method. The present case report outlines the use of Foa and Rothbaum's (1998) manual for this type of treatment in the year-long, 40-session treatment of Caroline, an adult female victim of child sexual abuse. The manual was supplemented by Caspar's (1995, 2007) Plan Analysis technique for individualized case formulation and treatment planning, along with Caspar's concept of the Motive-Oriented Therapeutic Relationship (MOTR). As indicated by standardized, quantitative measures, by changes in the client's behavior patterns, and by the client's subjective report, the treatment was very effective. An analysis of the therapy process illustrates the importance of a combination of manual-based procedures with individualized case formulations and interventions. The case is discussed in the context of enhancing the cognitive-behavioral treatment of PTSD.

The role of alliance in the relationship between therapist competence and outcome in brief psychodynamic psychotherapy.

Therapist competence is a key variable for psychotherapy research. Empirically, the relationship between competence and therapeutic outcome has shown contradictory results and needs to be clarified, especially with regard to possible variables influencing this relationship. A total of 78 outpatients were treated by 15 therapists in a very brief 4-session format, based on psychoanalytic theory. Data were analyzed by means of a nested design using hierarchical linear modeling. No direct link between therapist competence and outcome has been found, however, results corroborated the importance of alliance patterns as moderator in the relationship between therapist competence and outcome. Only in dyads with alliance change over the course of treatment was it clear that competence is positively related to outcome. These findings are discussed with regard to the importance for outcome of therapist competence and alliance construction processes.

Observer-rated Coping Associated with Borderline Personality Disorder: An Exploratory Study.

BACKGROUND: Little is known about coping specificities, as operationalization of the concept of affect regulation, in borderline personality disorder (BPD). It is most important to take into account methodological criticisms addressed to the self-report questionnaire approach and to compare BPD coping specificities to the ones of neighbouring diagnostic categories, such as bipolar disorder (BD). SAMPLING AND METHODS: The present exploratory study compared the coping profiles of N = 25 patients presenting BPD to those of N = 25 patients presenting BD and to those of N = 25 healthy controls. All participants underwent a clinical interview that was transcribed and rated using the Coping Patterns observer-rater system. RESULTS: Results partially confirmed study hypotheses and showed differences between BPD patients and healthy controls in all coping domains (competence, resources and autonomy), whereas the only coping domain presenting a BPD-specific lack of skills, compared with the BD patients, was autonomy, a set of coping strategies facing stress appraised as challenge. These coping processes were linked to general and BPD symptomatology. CONCLUSIONS: These results extend conclusions of earlier studies on affect regulation processes in BPD and bear important clinical implications, in the context of dialectical behavior therapy and other therapeutic approaches. Limitations of this exploratory study, such as the small sample size, are acknowledged. Copyright © 2012 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Coping can be reliably assessed in the narrative process in an non-structured interview frame. Patients with borderline personality disorder present with a specific lack of skills in affect regulation related to autonomy issues, compared to patients with bipolar disorder and healthy controls. Lack of skills in accommodation to distressing emotions in borderline personality disorder is related to symptom gravity and may be treated using radical acceptance strategies.

Cognitive errors assessed by observer ratings in bipolar affective disorder: relationship with symptoms and therapeutic alliance

The construct of cognitive errors is clinically relevant for cognitive therapy of mood disorders. Beck's universality hypothesis postulates the relevance of negative cognitions in all subtypes of mood disorders, as well as positive cognitions for manic states. This hypothesis has rarely been empirically addressed for patients presenting bipolar affective disorder (BD). In-patients (n = 30) presenting with BD were interviewed, as were 30 participants of a matched control group. Valid and reliable observer-rater methodology for cognitive errors was applied to the session transcripts. Overall, patients make more cognitive errors than controls. When manic and depressive patients were compared, parts of the universality hypothesis were confirmed. Manic symptoms are related to positive and negative cognitive errors. These results are discussed with regard to the main assumptions of the cognitive model for depression; thus adding an argument for extending it to the BD diagnostic group, taking into consideration specificities in terms of cognitive errors. Clinical implications for cognitive therapy of BD are suggested.

Fear and anxiety at the basis of adolescent externalizing and internalizing behaviors: a case study.

Juvenile delinquency is rarely associated with success in psychotherapeutic treatment. Up until now, few data have been recorded regarding possible overlaps or common features of conduct disorders with anxiety disorders. This case report of a delinquent adolescent's presenting an obsessive-compulsive disorder discusses possible underlying common features of externalizing and internalizing disorders, mainly in terms of fear and anxiety regulation. The successful psychotherapy is discussed with regard to efficient psychological assessment and treatment of delinquent adolescents, and it underlies the importance of detailed analysis of psychopathology in cases of juvenile delinquency.

Identifying psychotic defenses in a clinical interview.

The Defense Mechanisms Rating Scales (DMRS), one of the most widely used and validated instruments in the study of defense mechanisms, does not include psychotic defenses. The Psychotic-DMRS (P-DMRS) has been developed to include 6 psychotic defense mechanisms: psychotic denial, autistic withdrawal, distortion, delusional projection, fragmentation, and concretization. We discuss psychotic defenses, including the difference between psychotic defenses and psychotic symptoms. Six clinical illustrations demonstrate how the 6 P-DMRS defenses can be identified in patients' narratives selected from the transcripts of dynamic interviews. Implications with respect to patient evaluation and treatment are discussed.

Révéler son humanité ? L'autorévélation du thérapeute à la lumière de la recherche empirique

L'autorévélation, consistant pour un thérapeute à révéler des informations personnelles sur lui-même à sonclient, pourrait être une technique thérapeutique bénéfique. Il existe néanmoins beaucoup de définitions de ceconcept. Malgré cela, les recherches empiriques montrent que l'autorévélation serait perc¸ue favorablementpar les clients et qu'elle pourrait influencer la perception de leur thérapeute. Plus encore, elle influenceraitpositivement les résultats d'un traitement. Les autorévélations concernant les sentiments dans l'immédiat dela thérapie ainsi que la relation thérapeute-client seraient particulièrement efficaces pour gérer les événementsproblématiques en permettant aux affects d'être exprimés et acceptés et en fournissant un apprentissageinterpersonnel aux clients. Plusieurs auteurs conseillent finalement d'utiliser cette technique de manière peufréquente, au sujet des thèmes modérément intimes mais pertinents par rapport à la thérapie, en examinant lesbesoins spécifiques de chaque client, et en ayant toujours comme intention d'aider ces derniers ou d'améliorerla relation thérapeutique.

Les méthodes d'études de cas en psychothérapie: perspectives actuelles [Methods of psychotherapy case studies: current perspectives].

There is a renewal of interest among psychotherapy researchers and psychotherapists towards psychotherapy case studies. This article presents two paradigms that have greatly influenced this increasing interest in psychotherapy case studies : the pragmatic case study and the theory-building case study paradigm. The origins, developments and key-concepts of both paradigms are presented, as well as their methodological and ethical specificities. Examples of case studies, along with models developed, are cited. The differential influence of the post-modern schools on both paradigms are presented, as well as their contribution to the field of methods of psychotherapy case studies discussed and assessed in terms of relevance for the researcher and the psychotherapist.

Intégrer clinique et recherche: le modèle de la clarification selon R. Sachse

Cet article présente une introduction au modèle de la clarification selon Rainer Sachse. Ce modèle s'inspire avant tout des courants psychothérapeutiques centrés sur l'émotion et comprend un certain nombre de notions et de techniques nouvelles et spécifiques. Ainsi, les niveaux de conceptualisation du patient en séance sont présentés et la notion de clarification (Klärung) ou d'explicitation des schémas affectifs discutée. Pour certains patients, notamment avec un trouble de la personnalité, le travail d'explicitation du contenu affectif doit être précédé par un travail sur le niveau relationnel, ce qui est conceptualisé par le modèle de la double régulation de l'action. Ce modèle est brièvement présenté, discuté en lien avec les concepts de la clarification et des implications cliniques abordées. Finalement, nous désirons apporter des éléments de validation empirique du modèle de la clarification selon R. Sachse ; des implications pour la formation des psychothérapeutes-experts sont proposées. This article presents an introduction to the clarification model according to Rainer Sachse. This model is mainly based on emotion-focused psychotherapy approaches and comprises new notions and specific techniques. Thus, we present the conceptualization levels of a patient in session, as well as the notion of clarification (Klärung) of affective schemas. For certain patients, in particular with Personality Disorders, relationship work needs to precede clarification work on affective contents. These dynamics are conceptualized in the dual action regulation model, which is briefly presented and discussed with regard to the notion of clarification ; clinical implications are added. Finally, we would like to present empirical validation studies of the clarification model by R. Sachse and implications for the training of psychotherapists as experts.