The effects of borderline pathology on short-term psychodynamic psychotherapy for depression

Short-term psychoanalytic psychotherapy with depressed adolescents: Comparing in-session interactions in good and poor outcome cases

Objective: To identify and describe in-session interaction patterns between psychoanalytic therapists and adolescents diagnosed with major depressive disorder, comparing good and poor outcome cases. Method: Audio recordings for 100 psychotherapy sessions from 10 Short-Term Psychoanalytic Psychotherapies were analysed using the Adolescent Psychotherapy Q-Set (APQ). The cases and sessions were evenly divided into two groups (poor outcome and good outcome, 5 patients and 50 sessions per group). Interaction patterns were analysed with an Exploratory Factor Analysis (EFA), while group differences were assessed through t-tests. Results: The EFA revealed three factors: (1) "Open, engaged young person working collaboratively with a therapist to make sense of their experiences", (2) "Directive therapist with a young person fluctuating in emotional state and unwilling to explore", (3) "Young person expressing anger and irritation and challenging the therapist". Factor 1 was significantly more prominent in the good outcome cases, while factor 3, on the contrary, was more significantly related to the poor outcome cases. Factor 2 was equally present in both groups. Conclusion: Besides reinforcing to researchers and clinicians the association between a collaborative psychotherapy process with good outcomes, our findings also provide empirical data regarding the role of anger in adolescent depression and the psychotherapy process.

Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features

This study examines the relationship between patient personality characteristics and therapeutic integration. Within a sample of patients (N=93) receiving outpatient psychodynamically- oriented psychotherapy, we assessed patient Borderline and Emotionally Dysregulated personality features through the Shedler-Westen Assessment Procedure (SWAP-200), and therapeutic technique using the Comparative Psychotherapy Process Scale (CPPS) during an early treatment session. We examined personality dimensionally, psychotherapy interventions across different theoretical orientations, as well as psychotherapy integration. These analyses revealed an overlap between the Borderline Clinical Prototype and the Emotionally Dysregulated-Dysphoric Q-factor, with the former associated with higher use of integration and the latter associated with higher use of either psychodynamicinterpersonal or cognitive-behavioural interventions. Secondary analyses also indicated the greater presence of interventions oriented towards emotional exploration and to the didactic instruction of effective symptom coping techniques across both of these personality subtypes early in treatment. The key differences between these personality types, as well as the theoretical, empirical, and clinical implications of these findings are discussed.

The relationship between prototype ratings of personality and self and interpersonal functioning with an adolescent inpatient sample

Personality pathology is conceptualized, in part, as impairments in self and interpersonal functioning. Although most of the research has focused on adult samples, fewer have looked at this relationship in adolescent samples. This paper investigates the relationship between clinician-rated personality prototypes, the Shedler-Westen Assessment Procedure-Prototype Matching Adolescent Version (SWAP-A-P) derived from the SWAP-II-A, and a measure of self and interpersonal functioning, the Social Cognition and Object Relation Scale-Global Rating (SCORS-G). Clinicians rated 66 adolescents hospitalized at a safety net teaching hospital in the northeast. The patient's individual and group therapist rated the patients at discharge using the SWAP-A-P and the SCORS-G at discharge blind to each other's ratings. Results showed that more severe personality pathology was linked with more impairments in self and interpersonal functioning.

What interpersonal problems are related to different therapeutic techniques early in treatment?

The current study seeks to explore the relationship between patient-reported interpersonal problems and therapist interventions in early psychodynamic psychotherapy for 71 outpatients. Pretreatment ratings on the Inventory of Interpersonal Problems Circumplex Scales (IIP-C) total and subscale scores were examined in relation to early treatment process. Independent clinicians reliably rated therapist use of psychodynamic-interpersonal (PI) and cognitive-behavioural (CB) interventions using the Comparative Psychotherapy Process Scale (CPPS) over two early treatment sessions (third and ninth). Intraclass correlation (ICC) values were in the excellent range for CPPS-PI and CPPS-CB scale scores (CPPS-PI = 0.86; CPPS-CB = 0.78). A significant positive correlation was found between interpersonal problems and global PI therapist technique. A significant positive correlation was also found between interpersonal problems and specific PI interventions, most significantly experience and expression of feelings in session. In specific interpersonal problem subscales, most significant was that Cold/Distant and Socially Inhibited octants positively related to global PI and to specific PI techniques, including exploration of uncomfortable feelings. Multiple regression analyses revealed most significantly that CPPS Intervention 7 (discussion of patient-therapist relationship; positive) and CPPS Intervention 11 (therapist explanation of rationale behind treatment; negative) explained 15.6% of variance in interpersonal problem score. These findings demonstrate that the use of psychodynamic techniques tend to occur alongside patient-reported interpersonal problems early in psychotherapy treatment. Clinical implications are discussed for this area of research, and future directions are explored.

Psychodynamic techniques related to outcome for anxiety disorder patients at different points in treatment

Although psychodynamic therapy has a well-articulated model of therapeutic change for anxiety, few empirical studies have examined specific treatment interventions related to symptom improvement. We examined the degree of adherence to a psychodynamic model of therapy (Blagys and Hilsenroth [Clin Psychol 7:167-188, 2000) related to changes in anxiety symptoms across early treatment process. Secondary analyses also examined the use of specific psychodynamic techniques across early treatment process in relation to symptom change. The current study sought to extend the findings of , who found a relationship between the use of psychodynamic techniques in the third session (independent clinical ratings) and reduction in anxiety symptoms at posttreatment (r = 0.46, p = 0.04). Using the same sample of anxiety disorder patients (N = 20), we found a significant relationship between psychodynamic technique and posttreatment change in anxiety symptoms at the ninth session (r = 0.49, p = 0.03) and the mean levels of psychodynamic technique across both third and ninth sessions (r = 0.53, p = 0.02). In addition, specific psychodynamic techniques demonstrated significant relationships or moderate to large effects with posttreatment changes in anxiety symptoms at the third and ninth sessions as well as mean ratings across early treatment (third and ninth sessions). These findings indicate that therapist focus on cyclical intrapersonal patterns in patient actions, feelings, or experience as well as suggestions of alternative ways to understand these experiences or events not previously recognized by the patient (i.e., interpretation) in the early treatment process were particularly helpful in reducing posttreatment anxiety symptoms. Clinical implications and areas for future research will be discussed.

Patient Crying in Psychotherapy: Who Cries and Why?

AIM

The aim of the present study is to further the understanding of who cries in therapy and the relation of technique with crying behaviour in therapy.

METHOD

Psychological assessment feedback sessions, prior to the initiation of formal therapy for 52 patients beginning psychotherapy at a university-based clinic were coded for discrete crying segments. Data about patient characteristics and the process of the session were collected at the time of the session. Therapist's interventions were recorded verbatim and independently rated.

RESULTS

The number of times a patient cried during their session correlated negatively with global assessment of functioning scores and positively with measures of borderline personality disorder pathology as well as a measure of severity of childhood sexual abuse. Patients' crying behaviour demonstrated significant negative correlations with the overall experience of the session (bad/good), smoothness and positivity. Group differences between criers and non-criers reflected these trends as well. No significant correlations or group differences were found with regard to patient-rated or therapist-rated alliance as it relates to crying behaviour. Analysis indicates that therapist intervention prior to patient crying most often encouraged the exploration and expression of difficult affect, new perspectives on key issues or the patient's fantasies and wishes.

DISCUSSION

Our study addresses a significant gap in the clinical literature on crying. Crying behaviour seems to be related to certain clinical variables and has a negative impact on patient experience of the session in which they cry, although the alliance remained unaffected.

LIMITATIONS

Small sample, outpatients with mild/moderate psychopathology and graduate trainees provided therapy.

KEY PRACTITIONER MESSAGE

Patients with greater problems in emotional dysregulation, borderline personality disorder symptoms and greater severity of childhood sexual abuse are more likely to display greater affective intensity during the beginning of treatment. Results suggest that the alliance may remain strong despite patients experiencing a session in which they cried as difficult. Therapeutic interventions that focus on affect, new understanding of old patterns and patient fantasies with outpatient clinical populations appeared to be associated with crying in session.

Therapeutic interventions related to outcome in psychodynamic psychotherapy for anxiety disorder patients

This is the first study with acceptable inter-rater reliability to examine specific therapeutic techniques related to change in anxiety disorder patients during short-term psychodynamic psychotherapy. The study first examined the effectiveness of short-term psychodynamic psychotherapy and results showed significant and positive pre-/post-treatment changes on both patient and independent clinical ratings for anxiety, global symptomatology, relational, social, and occupational functioning. Likewise, the majority of patients (76%) reported anxiety symptoms within a normal distribution at termination. Importantly, psychodynamic interventions rated early in treatment (third/fourth session) were positively related to changes in anxiety symptoms. Further, results showed that several individual psychodynamic techniques were meaningfully related to outcome including (1) focusing on wishes, fantasies, dreams, and early memories; (2) linking current feelings or perceptions to the past; (3) highlighting patients' typical relational patterns; and (4) helping patients to understand their experiences in new ways. Clinical applications are discussed.

A longitudinal study of emotional experience, expressivity, and psychopathology in psychotherapy inpatients and psychologically healthy persons

The authors investigated changes of emotional experience and expressivity in 34 inpatients undergoing psychodynamic therapy and in 29 healthy persons who were assessed at parallel time intervals. Participants completed 2 measures of psychopathology (Symptom Checklist-90 Revised and Inventory of Interpersonal Problems-64) and took part in relationship episode interviews. The emotional experiences they reported and their nonverbal emotional expressivity during the interviews were assessed by independent raters. Regardless of when they were assessed, the patients reported a greater number of emotions and a greater variety of emotions. Psychopathology in the patient group decreased in the course of treatment, but there were no systematic changes in the emotional domain. The findings challenge the common notion of psychopathology being associated with impaired awareness and expression of emotions.

Core conflictual relationship theme--guided psychotherapy: Initial effectiveness study of a 16-session manualized approach in a sample of six patients

OBJECTIVE

This study examined the effectiveness of a manualized, 16-sessions, core conflictual relationship theme (CCRT)-based treatment.

DESIGN

Treatment effects were assessed for statistical and clinical significance in a pre- and post-therapy design.

METHODS

Six patients seeking help mostly for interpersonal difficulties received CCRT-based psychotherapy. The therapists were six supervised doctoral students. An average of four assessment sessions and one goal-setting session preceded 16 sessions of psychotherapy consisting mainly of interpretive work focused on one CCRT. Patients completed measures of general and treatment specific outcome indicators at the beginning and the end of therapy. Alliance measures were completed by patients after each session.

RESULTS

The alliance was strong and the treatment had high credibility. Parametric and non-parametric tests showed that patients significantly improved on the general measures of self-esteem, symptomatic distress, anxiety, and depression, as well as on the treatment specific measures of interpersonal functioning, use of immature defences, and CCRT-associated subjective discomfort, with large effect sizes.

CONCLUSIONS

These preliminary results suggest that this manualized, CCRT-based, treatment produces general and approach specific improvements. Replication is needed to ascertain its effectiveness with a larger sample size and within a controlled design.

Patient ratings of psychodynamic psychotherapy session activities and their relation to outcome

This study examines patient ratings of modality-specific technical interventions and their relation to therapeutic treatment change. The sample consisted of 55 individuals engaged in short-term psychodynamic psychotherapy at a university-based community outpatient treatment center. Results demonstrate that not only were patients capable of recognizing specific technical processes occurring within their psychotherapy, but also that those ratings were significantly related to measures of therapeutic outcome. Furthermore, patient ratings of session activities were found to be stable from early session rating to late in treatment. Findings support the conclusion that, as rated from the patient perspective, some degree of flexibility in and integration of modality-specific techniques is beneficial for outcome. Implications for future research and clinical practice are discussed.