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.

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.

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: rationale and design of a randomized controlled trial.

BACKGROUND: A few recent studies have found indications of the effectiveness of inpatient psychotherapy for depression, usually of an extended duration. However, there is a lack of controlled studies in this area and to date no study of adequate quality on brief psychodynamic psychotherapy for depression during short inpatient stay exists. The present article describes the protocol of a study that will examine the relative efficacy, the cost-effectiveness and the cost-utility of adding an Inpatient Brief Psychodynamic Psychotherapy to pharmacotherapy and treatment-as-usual for inpatients with unipolar depression. METHODS/DESIGN: The study is a one-month randomized controlled trial with a two parallel group design and a 12-month naturalistic follow-up. A sample of 130 consecutive adult inpatients with unipolar depression and Montgomery-Asberg Depression Rating Scale score over 18 will be recruited. The study is carried out in the university hospital section for mood disorders in Lausanne, Switzerland. Patients are assessed upon admission, and at 1-, 3- and 12- month follow-ups. Inpatient therapy is a manualized brief intervention, combining the virtues of inpatient setting and of time-limited dynamic therapies (focal orientation, fixed duration, resource-oriented interventions). Treatment-as-usual represents the best level of practice for a minimal treatment condition usually proposed to inpatients. Final analyses will follow an intention-to-treat strategy. Depressive symptomatology is the primary outcome and secondary outcome includes measures of psychiatric symptomatology, psychosocial role functioning, and psychodynamic-emotional functioning. The mediating role of the therapeutic alliance is also examined. Allocation to treatment groups uses a stratified block randomization method with permuted block. To guarantee allocation concealment, randomization is done by an independent researcher. DISCUSSION: Despite the large number of studies on treatment of depression, there is a clear lack of controlled research in inpatient psychotherapy during the acute phase of a major depressive episode. Research on brief therapy is important to take into account current short lengths of stay in psychiatry. The current study has the potential to scientifically inform appropriate inpatient treatment. This study is the first to address the issue of the economic evaluation of inpatient psychotherapy. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ACTRN12612000909820).

Assimilation des expériences problématiques: une étude de cas de psychothérapie psychodynamique limitée dans le temps [Assimilation of problematic experiences: a case study on short-term dynamic psychotherapy].

The assimilation model is a qualitative and integrative approach that enables to study change processes that occur in psychotherapy. According to Stiles, this model conceives the individual's personality as constituent of different voices; the concept of voice is used to describe traces left by past experiences. During the psychotherapy, we can observe the progressive integration of the problematic voices into the patient's personality. We applied the assimilation model to a 34-session-long case of an effective short-term dynamic psychotherapy. We've chosen eight sessions we transcribed and analyzed by establishing points of contact between the case and the theory. The results are presented and discussed in terms of the evolution of the main voices in the patient.

Specificities of psychodynamic psychotherapy in the medically ill

Psychodynamic psychotherapy with patients suffering from somatic diseases is based on general principles of psychodynamic understanding, such as the influence of development and biographical elements on patient.s adaptation to illness or the role of defense mechanisms when facing existential threat. However, differences exist, such as the adaptation of the therapeutic setting, which thus loses some of its diagnostic and therapeutic power, or the early emergence of powerful transference, which cannot always be interpreted by the therapist. In addition, psychodynamic psychotherapy in the medically ill has some specificities, which differentiate it from classical psychoanalytic theory. The specificities concern, for example, transference of the medically ill, which is more adequately conceived by concepts of the existential analysis (Daseinsanalyse), or the patient.s loss of a sense of continuity, which needs an understanding beyond psychological theory taking into account philosophical (e.g. phenomenology), anthropological and ethical concepts.

An Empirical Investigation of Defense Interpretation Depth, Defensive Functioning, and Alliance Strength in Psychodynamic Psychotherapy.

The present study examined the relationship between depth of defense interpretations by therapists, and patient defensive functioning, on the therapeutic alliance in a sample of 36 patients undergoing short-term dynamic psychotherapy. Defense interpretation depth was defined as the degree to which therapist interpretations contained information regarding the motivation for patient defenses and historical origins of the defensive processes (Greensen, 1967). Mean depth of interpretation was compared between sessions that were identified beforehand as either high-alliance or low-alliance sessions using the Helping Alliance Questionnaire (HAq-II: Luborsky et al., 1996). Results indicated that defensive functioning was correlated to defense interpretation depth in low-alliance sessions. Moreover, mean depth of interpretation was also higher in low-alliance sessions, pointing to the possible "destabilizing" effects that these interpretations may have on both defensive functioning and the therapeutic alliance. These results are discussed within the context of previous studies of therapeutic technique in dynamic psychotherapy.

Psychotherapy for Personality Disorders in a Natural Setting: A Pilot Study over Two Years of Treatment.

Long-term assessment of the effects of psychotherapy for personality disorders (PDs) in a natural environment is an important task. Such research contributes to enlarge the practice-based evidence, embedded in broad collaborations between clinicians and researchers in psychotherapy for PDs. The present pilot study used rigorous assessment procedures and incorporated feedback loops of outcome information to the therapists in demonstrating the effects of psychotherapy for PD in a natural setting. The number of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for any PD was the primary outcome (along with psychological distress, depression, impulsiveness, and quality of life as secondary measures), assessed at intake, 6, 12, 18, and 24 months of psychotherapy for N = 13 patients with PD. Data were analyzed using hierarchical linear modeling. Results demonstrated a large pre-post effect (d = 2.22) for the observer-rated measure (primary outcome), and small to medium effects for the secondary outcomes; these results were corroborated by a steady decrease of symptoms over all five time points, which was significant for several outcomes. These results add a piece to the literature by demonstrating the effects of long-term psychotherapy for PDs in increasingly diverse contexts and suggest that practice-oriented research can be carried out in a collaborative and systematic manner.