Les méthodes d'études de cas en psychothérapie : perspectives actuelles

Les études de cas en psychothérapie connaissent une phase de renouveau auprès des chercheurs en psychothérapie et des psychothérapeutes. L'auteur discute de deux paradigmes qui ont grandement influencé ce nouvel intérêt : le paradigme pragmatique et le paradigme qui vise la construction d'une théorie. L'article présente les origines, les développements et les concepts clés des deux paradigmes et leurs spécificités méthodologiques et éthiques. Des exemples d'études de cas ou de modèles au sein des paradigmes sont évoqués. L'influence différentielle des courants postmodernes sur les deux paradigmes, et leurs apports respectifs dans le champ des méthodes d'études de cas, sont discutés et évalués par rapport aux implications pour le chercheur et le psychothérapeute.

Effects of motive-oriented therapeutic relationship in a ten-session general psychiatric treatment of borderline personality disorder: a randomized controlled trial.

Background: Motive-oriented therapeutic relationship (MOTR) was postulated to be a particularly helpful therapeutic ingredient in the early treatment phase of patients with personality disorders, in particular with borderline personality disorder (BPD). The present randomized controlled study using an add-on design is the first study to test this assumption in a 10-session general psychiatric treatment with patients presenting with BPD on symptom reduction and therapeutic alliance. Methods: A total of 85 patients were randomized. They were either allocated to a manual-based short variant of the general psychiatric management (GPM) treatment (in 10 sessions) or to the same treatment where MOTR was deliberately added to the treatment. Treatment attrition and integrity analyses yielded satisfactory results. Results: The results of the intent-to-treat analyses suggested a global efficacy of MOTR, in the sense of an additional reduction of general problems, i.e. symptoms, interpersonal and social problems (F1, 73 = 7.25, p < 0.05). However, they also showed that MOTR did not yield an additional reduction of specific borderline symptoms. It was also shown that a stronger therapeutic alliance, as assessed by the therapist, developed in MOTR treatments compared to GPM (Z55 = 0.99, p < 0.04). Conclusions: These results suggest that adding MOTR to psychiatric and psychotherapeutic treatments of BPD is promising. Moreover, the findings shed additional light on the perspective of shortening treatments for patients presenting with BPD. © 2014 S. Karger AG, Basel.

A phase I dose-escalation study of the immunocytokine EMD 521873 (Selectikine) in patients with advanced solid tumours.

BACKGROUND: EMD 521873 (Selectikine), an immunocytokine comprising a DNA-targeting antibody, aimed at tumour necrosis, fused with a genetically modified interleukin-2 (IL-2) moiety, was investigated in this first-in-human phase I study. METHODS: Patients had metastatic or locally advanced solid tumours failing previous standard therapy. Selectikine was administered as a 1-hour intravenous infusion on 3 consecutive days, every 3weeks. A subgroup of patients also received 300mg/m(2) cyclophosphamide on day 1 of each cycle. Escalating doses of Selectikine were investigated with the primary objective of determining the maximum tolerated dose (MTD). RESULTS: Thirty-nine patients were treated with Selectikine alone at dose levels from 0.075 to 0.9mg/kg, and nine were treated at doses of 0.45 and 0.6mg/kg in combination with cyclophosphamide. A dose-dependent linear increase of peak serum concentrations and area under curve was found. The dose-limiting toxicity was grade 3 skin rash at the 0.9mg/kg dose-level; the MTD was 0.6mg/kg. Rash and flu-like symptoms were the most frequent side-effects. No severe cardiovascular side-effects (hypotension or vascular leak) were observed. At all dose-levels, transient increases in total lymphocyte, eosinophil and monocyte counts were recorded. No objective tumour responses, but long periods of disease stabilisation were observed. Transient and non-neutralising Selectikine antibodies were detected in 69% of patients. CONCLUSIONS: The MTD of Selectikine with or without cyclophosphamide administered under this schedule was 0.6mg/kg. The recommended phase II dose was 0.45-0.6mg/kg. Selectikine had a favourable safety profile and induced biological effects typical for IL-2.

Alliance evolutions over the course of short-term dynamic psychotherapy: A case study

Background: Alliance evolutions, i.e. ruptures and resolutions over the course of psychotherapy, have been shown to be important descriptive features in different forms of psychotherapy, and in particular in psychodynamic psychotherapy. This case study of a client presenting elements of adjustment disorder undergoing short-term dynamic psychotherapy is drawn from a systematic naturalistic study and aims at illustrating, on a session-by-session-level, the processes of alliance ruptures and resolutions, by comparing both the client's and the therapist's perspectives. Method: Two episodes of alliance evolution were more fully studied, in relation to the evolution of transference, as well as the client's defensive functioning and core conflictual theme. These concepts were measured by means of valid, reliable observer-rater methods, based on session transcripts: the Defense Mechanisms Rating Scales (DMRS) for defensive functioning and the Core Conflictual Relationship Theme (CCRT) for the conflicts. Alliance was measured after each session using the Helping Alliance questionnaire (HAq-II). Results: The results indicated that these episodes of alliance rupture and resolutions may be understood as key moments of the whole therapeutic process reflecting the client's main relationship stakes. Illustrations are provided based on the client's in-session processes and related to the alliance development over the course of the entire therapy.

Are relationship patterns with significant others reenacted with the therapist?: a study of early transference reactions.

This study examines how patients' relationship patterns are reenacted with the therapist during the first sessions of psychotherapy. Forty (N = 40) outpatients treated with a Brief Psychodynamic Intervention were included in the study. Their narratives of relationship episodes with significant others (e.g., mother, father, romantic partner, colleagues) were compared with relationship episodes with their therapist using the Core Conflictual Relationship Theme method. The Core Conflictual Relationship Theme focuses on 3 aspects of patients' relationship narratives: what the patient wants from others or from self; how others react to his/her wish; and how the patient consequently reacts. Results showed that 60% of patients display similar relationship patterns with their therapist and with significant others. The patterns that were reenacted with the therapist were not the most pervasive ones but were similar to those found in relationship episodes involving parents or romantic partners. These findings provide some support for the clinical concept of repetition of internalized relational patterns with the therapist very early in psychotherapy. Clinical implications are discussed.

Beyond splitting: observer-rated defense mechanisms in borderline personality disorder

Defense mechanism is a key concept in the psychoanalytic psychopathology of borderline personality disorder (BPD). Theoretical and empirical elaborations on this question are briefly reviewed and discussed with respect to process assessment of defense mechanisms; we put forward observer-rater methodology as an accurate means of assessing unconscious in-session processes. A sample of 25 patients presenting with BPD were interviewed, as were subjects from a matched control group without psychiatric symptoms (n = 25), using a psychodynamic interview paradigm. These interviews were transcribed and rated using the Defense Mechanisms Rating Scales. The results indicate that, compared to controls, patients with BPD used higher percentages of a action, borderline, disavowal, narcissistic, and hysteric defenses, along with lower levels of mature and obsessional defenses. Overall defensive functioning was significantly lower in the patients with BPD, compared to controls. Narcissistic defenses were related with symptom level. These results are discussed in light of previous studies on defensive functioning of BPD and the literature on psychoanalytic psychopathology. These results have several important clinical implications.

La chaise vide en psychothérapie : origines et développements = The empty chair in psychotherapy: Origins and developments

Les techniques utilisant la chaise vide ou le dialogue sur deux chaises sont des moyens qui permettent le déploiement de techniques expérientielles dans différentes formes de psychothérapie. Cet article vise à retracer l'origine de ces techniques dans les courants Gestalt et centré sur la personne, pour ensuite présenter quelques développements actuels au sein des thérapies expérientielles au sens large. Les techniques présentées sont classées selon leur finalité primordiale, à savoir : leur utilisation dans le but de clarifier et de construire du sens et leur utilisation dans le but de modifier des déterminants internes du problème. Les techniques suivantes sont brièvement présentées, illustrées par des vignettes cliniques et discutées : élaboration du conflit interne ; élaboration de l'auto-interruption ; élaboration d'un conflit avec une personne significative ; dialogue d'apaisement ; éléments cognitifs du jeu de rôle avec une seule personne ; éléments affectifs du jeu de rôle avec une seule personne. Nous discutons les travaux de recherche mettant en évidence l'efficacité et l'effectivité de ces techniques et terminons par des réflexions au sujet de l'indication différentielle de ces techniques, avec une réflexion au sujet des perspectives cliniques et de recherche. © 2013 Publié par Elsevier Masson SAS pour la Société française de psychologie.

Quelle place pour la psychothérapie dans la psychiatrie publique [What place for psychotherapy in public psychiatry?].

The question of the place of psychotherapy in psychiatric public care is posed in this article. We will address this question first by presenting two clinical and research programmes which were implemented in a clinical psychiatric unit, section Karl Jaspers (Service of General Psychiatry) of the Department of Psychiatry CHUV, in Lausanne with the collaboration of the University Institute of Psychotherapy. The first one puts forward psychodynamic psychotherapy of depressed inpatients; the clinical programme and the research questions on efficacy of this treatment are discussed. The second focuses on the early treatment of patients with Borderline Personality Disorder, in particular in its research question on the effect of the motive-oriented therapeutic relationship in this process. We conclude by underlining the convergences of the two programmes.

The cognitive errors and coping patterns of child molesters as assessed by external observers: a pilot study

Cognitive errors (CE) and coping strategies (CS) are the focus of most cognitive-behavioral treatments for incarcerated child molesters. Several studies have reported differences in CEs and CSs between child molesters and controls. However, the vast majority of these studies assessed cognitive errors and coping using questionnaires, which are known to present a number of important limitations. This pilot study aimed to compare the CEs and CSs of N = 17 incarcerated child abusers and N = 12 controls using observer-rated methods, namely the Cognitive Error Rating Scale (CERS; Drapeau et al., 2005) and the Coping Action Pattern Rating Scale (CAPRS; Perry, Drapeau, & Dunkley, 2005). Results showed that child molesters presented more cognitive errors, in particular positive selective abstraction, and lower coping functioning, such as escape strategies. Treatment and research implications, including the use of observer-rated methods, are discussed.

Change in cognitive errors and coping over the course of brief psychodynamic intervention.

OBJECTIVE: Cognitive change over the course of psychodynamic psychotherapy has been postulated by several models, but has rarely been studied. Based on the adaptive skills model (Badgio, Halperin, & Barber, 1999), it is reasonable to expect that very brief dynamic psychotherapy may be associated with change in coping patterns and cognitive errors (also known as cognitive distortions) y. METHOD: N = 50 outpatients presenting with various psychiatric disorders and undergoing 4 sessions of Brief Psychodynamic Intervention (BPI; Despland, Drapeau, & de Roten, 2005; Despland, Michel, & de Roten, 2010) were included in this naturalistic study (mean age: 31 years; 56% female; all Caucasian). Cognitive errors and coping strategies were assessed using the Cognitive Errors Rating Scale (Drapeau et al., 2008) and Coping Patterns Rating Scale (Perry et al., 2005). These observer rated methods were applied to the verbatim transcriptions of all 4 therapy sessions completed by each patient. RESULTS: Results indicate change in both cognitive errors and coping patterns over the course of BPI, including an increase in the Overall Coping Functioning and a decrease in unhelpful coping processes, such as isolation, which reflects a shift in participant appraisal towards stress appraised as a challenge at the end of treatment. These changes predicted symptom change at the end of treatment. While cognitive errors also changed over the course of BPI, no predictive effect was found with regard to symptom change. CONCLUSIONS: These results are interpreted within the framework of common change principles in psychotherapy. Implications and future research are discussed.