Predictive value of object relations for therapeutic alliance and outcome in psychotherapy for depression: an exploratory study

Patient Extratherapeutic Interpersonal Problems and Response to Psychotherapy for Depression

OBJECTIVES

This paper aimed to synthesize empirical findings of patient extratherapeutic interpersonal variables associated with individual psychotherapy treatment outcomes in adult outpatients with depression.

METHODS

A systematic search strategy was used to identify relevant studies. Thematic analysis was used to identify recurring themes in the findings.

RESULTS

Forty studies met search criteria. Three themes of patient extratherapeutic interpersonal variables were identified: capacity to engage with others, capacity to navigate relationships, and capacity to achieve intimacy, progressing from basic to advanced levels of interpersonal interaction. Interpersonal variables such as interpersonal distress and style, attachment orientation, and quality of object relations were particularly useful in predicting treatment outcomes, whereas access to social support and marital status provided mixed results, likely because they do not account for relationship quality.

CONCLUSIONS

Recognizing variables associated with treatment response can help clinicians identify patients at risk for nonresponse and guide efforts for adapting existing therapies and developing new ones.

The Developmental Profile Inventory: Constructing a Clinically Useful Self-Report for Levels of Psychodynamic Personality Functioning

OBJECTIVE

The Developmental Profile Inventory (DPI) was constructed to assess psychodynamic personality functioning by self-report.

METHOD

On the basis of the frame of reference of the Development Profile interview method, a self-report was developed covering 3 domains, self, interpersonal functioning, and problem-solving strategies, which represent 6 maladaptive and 3 adaptive developmental levels of psychodynamic functioning. The DPI was administered to patients with personality disorders who were receiving psychotherapy (N=179) and to normal controls (N=228).

RESULTS

The internal reliabilities of the subscales were in general in the fair to good range in the patient sample, (α=0.67 to 0.88, ωh=0.52 to 0.87) and adequate to good in the healthy controls (α=0.71 to 0.91, ωh=0.71 to 0.90). Mean item-rest correlations were adequate (0.30 to 0.50). Test-retest reliability was good (intraclass correlation=0.73 to 0.91). The hypothesized factorial structure of the DPI with 9 subscales organized in 3 clusters was partly confirmed by confirmatory factor analysis χ/df=2.37, root mean square error of approximation=0.060, root mean residual square=0.078, and comparative fit index=0.630, with each factor showing over 80% standardized loadings >0.30, and at least 75% loadings >0.40. The DPI discriminated patients and healthy controls in a meaningful way. Correlations among the DPI and other self-report measures of global personality pathology and psychological complaints showed satisfactory convergent and discriminant validity.

CONCLUSIONS

The DPI is a promising self-report measure for assessing both adaptive and maladaptive patterns of psychodynamic personality functioning. The appropriate initial psychometric properties justify proceeding with more formal tests of construct validity and predictive performance in broader mental health settings.

The physician's quality of life: Relationship with ego defense mechanisms and object relations

OBJECTIVE

To assess whether ego defense mechanisms and object relations (the way an individual subjectively experiences his/her relationships with others) are related to quality of life among physicians.

METHODS

In this cross-sectional mail survey, 602 physicians from Botucatu, SP, Brazil, were sent a socio-demographic questionnaire, the Bell Object Relations and Reality Testing Inventory-Form O (BORRTI-O), the Defense Style Questionnaire-40 (DSQ-40), and the World Health Organization Abbreviated Instrument for Quality of Life Assessment (WHOQOL-BREF).

RESULTS

198 questionnaires (33%) with valid responses were obtained. High BORRTI-O scores (indicative of pathology) on the alienation, egocentricity and insecure attachment subscales were associated with reduced WHOQOL-BREF scores for the psychological health and social relationship domains. Immature ego defense mechanisms were associated with lower WHOQOL-BREF scores for all domains. No significant associations of WHOQOL-BREF scores with working hours, workplace or monthly income were observed in the study population

CONCLUSIONS

WHOQOL-BREF scores correlated with mature defense mechanisms and normal object relations, suggesting an association between psychological maturity and quality of life among physicians.

Fatores associados à formação da aliança terapêutica na psicoterapia obrigatória

O objetivo deste estudo foi identificar de que forma se estabelece a aliança terapêutica (AT) em pacientes encaminhados de forma obrigatória para a psicoterapia, em comparação aos pacientes que buscam atendimento psicoterapêutico voluntariamente, verificando-se também as características das representações de objeto, mecanismos de defesa, percepção de coerção, e gravidade dos sintomas. Participaram da pesquisa 51 sujeitos, sendo 15 casos em psicoterapia obrigatória e 36 casos em tratamento voluntário. Ambos os grupos foram selecionados em uma instituição pública de saúde que oferece psicoterapia para funcionários públicos municipais. Os resultados apontaram que apesar dos pacientes obrigatórios apresentarem sintomas mais graves, foi possível o estabelecimento da AT. Além disso, o status de paciente obrigatório não influenciou o estabelecimento da AT e sim a percepção de coerção na procura de atendimento.

Twelve-year history of late-life depression and subsequent feelings to God

OBJECTIVES

Growing evidence shows several possible relations between religiousness and late-life depression. Emotional aspects of religiousness such as facets of the perceived relationship with God can be crucial in this connection. The aim of the current study was to examine the association between the course of late-life depression and feelings about God and religious coping.

DESIGN

Longitudinal survey study; naturalistic; 12-year follow-up.

SETTING

Longitudinal Aging Study Amsterdam; population-based, in three regions in The Netherlands.

PARTICIPANTS

A subsample of 343 respondents (mean age: 77.2 years), including all respondents with high levels of depressive symptoms at any measurement cycle between 1992 and 2003 (assessed by using the Center for Epidemiologic Studies Depression Scale and the Diagnostic Interview Schedule) and a random sample of nondepressed respondents who completed a postal questionnaire in 2005.

MEASUREMENTS

Scales on God Image and Religious Coping. Twelve-year depression course trajectories serve as predicting variables and are specified according to recency and seriousness.

RESULTS

Persistent and emergent depression are significantly associated with fear of God, feeling wronged by God, and negative religious coping. In terms of negative religious coping, significant associations were observed after adjustment for concurrent depression with a history of repeated minor depression and previous major depression.

CONCLUSIONS

Late-life depression seems to maintain a pervasive relationship over time with affective aspects of religiousness. Religious feelings may parallel the symptoms of anhedonia or a dysphoric mood and could represent the experience of an existential void.

Self-concept and quality of object relations as predictors of outcome in short- and long-term psychotherapy

BACKGROUND

Quality of object relations and self-concept reflect clinically relevant aspects of personality functioning, but their prediction as suitability factors for psychotherapies of different lengths has not been compared. This study compared their prediction on psychiatric symptoms and work ability in short- and long-term psychotherapy.

METHODS

Altogether 326 patients, 20-46 years of age, with mood and/or anxiety disorder, were randomized to short-term (solution-focused or short-term psychodynamic) psychotherapy and long-term psychodynamic psychotherapy. The Quality of Object Relations Scale (QORS) and the Structural Analysis of Social Behavior (SASB) self-concept questionnaire were measured at baseline, and their prediction on outcome during the 3-year follow-up was assessed by the Symptom Check List Global Severity Index and the Anxiety Scale, the Beck Depression Inventory and by the Work Ability Index, Social Adjustment Scale work subscale and the Perceived Psychological Functioning scale.

RESULTS

Negative self-concept strongly and self-controlling characteristics modestly predicted better 3-year outcomes in long-term therapy, after faster early gains in short-term therapy. Patients with a more positive or self-emancipating self-concept, or more mature object relations, experienced more extensive benefits after long-term psychotherapy.

LIMITATIONS

The importance of length vs. long-term therapy technique on the differences found is not known.

CONCLUSIONS

Patients with mild to moderate personality pathology, indicated by poor self-concept, seem to benefit more from long-term than short-term psychotherapy, in reducing risk of depression. Long-term therapy may also be indicated for patients with relatively good psychological functioning. More research is needed on the relative importance of these characteristics in comparison with other patient-related factors.

Best self visualization method with high-risk youth

The healing process of the Best Self Visualization Method (BSM) is described within the framework of meditation, neuroscience, and psychodynamic theory. Cases are drawn from the treatment of high-risk youth, who have histories of poverty, survival of sexual and physical abuse, and/or current risk for perpetrating abuse. Clinical use of BSM is demonstrated in two case illustrations, one of group psychotherapy and another of individual therapy.

Prevalence and risk factors for recurrence of depression five years after short term psychodynamic therapy

BACKGROUND

Follow-up research concerning the efficacy of treatment for depression is scarce and varies widely in clinical and methodological terms. Aim was to conduct a five-year follow-up study of recurrence of depression after short supportive Psychodynamic Treatment (PDT) alone or in combination with pharmacotherapy.

METHODS

Patients who had been treated five years previously for major depressive disorder in a randomised control trial comparing short supportive PDT alone or in combination with pharmacotherapy, were traced. Patients who completed treatment were included. Recurrent episodes in the past five years were identified using CIDI. Severity of symptoms after five years was measured with the Hamilton Rating Scale for Depression and sub-scales Depression, Anxiety and Somatisation of the self-report Symptom Checklist 90.

RESULTS

52 (37%) patients of the original sample were localised. 42% had suffered from one or more recurrences during the follow-up period. There was no significant difference between the group who had received psychotherapy and the group who had received combined therapy during the acute phase. Young women and patients with more residual depressive symptoms and less somatic symptoms directly after treatment, were more at risk for recurrence.

LIMITATIONS

Relatively small study population. Furthermore it was not known if patients received other treatment during the follow-up period.

CONCLUSIONS

The long-term efficacy of PDT (with or without antidepressants) seemed to be comparable with other psychotherapies for depression. But the high recurrence rate urges us to shift the focus of depression treatment to improving long-term outcome and to the prevention of recurrence, in particular for young women and patients with residual symptoms of depression.

Object relations and emotional processing deficits among psychiatric outpatients

The aim of this study was to investigate the association between object relations and emotional processing deficits among a general sample of psychiatric outpatients. The sample consisted of 104 patients consecutively referred to 2 outpatient clinics. Participants completed measures of object relations, emotional processing deficits, and general psychiatric distress. After controlling for the effect of current symptom distress, we found that object relations impairment was significantly associated with emotional processing deficits relating to unregulated emotions, signs of unprocessed emotions, and emotion suppression. These findings support the notion that patients with impoverished mental structures possess maladaptive strategies for modulating intense affects.

The developmental profile: validation of a theory-driven instrument for personality assessment

The Developmental Profile is an instrument for personality assessment. It covers both maladaptive and adaptive characteristics. The current study examined its internal consistency and construct validity in a Dutch sample of 763 participants from various clinical and nonclinical settings. The internal consistency reliability estimates were good for the clusters of levels (adaptive, neurotic, and primitive), although not for all separate levels. Confirmatory factor analysis showed an overall good fit, with the exception of the level of primary narcissism. Furthermore, empirical evidence was found for the interpretation of a patient's Developmental Profile according to increasing levels of aggregation, with as a highest level a single maladaptivity-adaptivity scale score. This scale significantly distinguished among different patient groups.