Clinical tasks of the dynamic interview

Change in Defense Mechanisms and Depression in a Pilot Study of Antidepressive Medications Plus 20 Sessions of Psychotherapy for Recurrent Major Depression

Treatment studies of major depression commonly focus on symptoms, leaving aside change in putative psychological risk factors. This pilot study examines the relationship between changes in eight depressive defenses and depressive symptoms. Twelve adults with acute recurrent major depression were given antidepressive medications and randomized to 20 sessions of either cognitive behavioral therapy or dynamic psychotherapy and followed for 1 year. Defenses were assessed using the Defense Mechanism Rating Scales (DMRS) and Defense Style Questionnaire (DSQ) at intake, termination, and 1-year follow-up. Depression improved highly significantly on both the Hamilton Rating Scale for Depression and Beck Depression Inventory, respectively, eight (67%) and nine (75%) patients attained recovery by 1 year. Depressive defenses improved significantly by termination (mean ES = 0.97; 95% confidence interval, 0.30-2.16), but retrogressed somewhat by 1 year. A mean of 12.17% (SD = 10.60) depressive defenses remained; only five subjects (50%) attained normative levels. Although causal relationships were not established, depressive defenses are promising candidates for mediating treatment effects on outcome of major depression.

Assessing Psychodynamic Conflict

Psychodynamic psychotherapies suggest that symptomatic relief is provided, in part, with the resolution of psychic conflicts. Clinical researchers have used innovative methods to investigate such phenomenon. This article aims to review the literature on quantitative psychodynamic conflict rating scales. An electronic search of the literature was conducted to retrieve quantitative observer-rated scales used to assess conflict noting each measure's theoretical model, information source, and training and clinical experience required. Scales were also examined for levels of reliability and validity. Five quantitative observer-rated conflict scales were identified. Reliability varied from poor to excellent with each measure demonstrating good validity. However a small number of studies and limited links to current conflict theory suggest further clinical research is needed.

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.

Specificities of defense mechanisms in bipolar affective disorder: relations with symptoms and therapeutic alliance

Defense mechanisms as a central notion of psychoanalysis have inspired various levels of interest in research in psychotherapy and psychopathology. Defense specificities have only recently been investigated systematically with regard to several clinical diagnoses, such as affective and personality disorders. For the present study, 30 inpatients diagnosed with Bipolar Affective Disorder I (BD) were interviewed. An observer-rater method, the Defense Mechanisms Rating Scales (DMRS), applied to session-transcripts, of assessment of defenses was used. A matched, nonclinical control group was introduced. Defense specificities in BD encompass a set of 5 immature defenses, of which omnipotence is linked with symptom level. The level of the therapeutic alliance is predicted by mature defenses. These results are discussed with regard to the psychological vulnerability of BD, and treatment implications for psychodynamic psychotherapy with such challenging patients are evoked.

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.

Subject and interviewer determinants of the adequacy of the dynamic interview

The dynamic interview is widely used in clinical and research settings, but factors associated with an adequate dynamic interview have not been systematically studied. Twenty-six subjects had a median of 3 dynamic interviews at least 6 months apart, conducted by 13 clinician interviewers. We examined the resulting 72 videotaped interviews for predictors of dynamic interview adequacy. Overall Dynamic Interview Adequacy was not explained by subject, occasion, or interviewer, per se, although significant negative effects were found for personality disorder and borderline personality scores and diagnoses of major depression and dysthymia, and positive effects for interviewer experience. Dynamic adequacy was related to overall breadth and depth of topic coverage (R2 = 0.424). However, in stepwise multiple linear regression, 5 therapeutic alliance factors together contributed an R2 = 0.768, diminishing the effect of topic coverage. Adequate dynamic interviews established a positive subject-interviewer interaction, facilitated subject exploration, and minimized technical interviewing errors, thereby yielding sufficient topic coverage.

The measurement of interview structure in five types of psychiatric and psychotherapeutic interviews

In a companion report (Beck & Perry, 2008), we reviewed the literature with regard to interview structure from which we derived seven operationalized quantitative measures. This report examines these measures as applied to five commonly used interview types--psychodynamic therapy sessions, dynamic interviews, Relationship Anecdote Paradigm (RAP) interviews, the Guided Clinical Interview and the Structured Clinical Interview for the DSM-IV axis I--each administered to the same six patients (n = 30). Two clinicians independently rated each interview using the Global Level of Interview Structure Scale (GLISS). Both the GLISS and six of the seven operationalized measures differed across interview types but not between subjects. Factor analysis yielded a single factor solution composed of five measures, not including a sixth measure (percentage of interviewer interventions that were questions) which was used as a solitary variable. Together the single factor and the percentage of questions predicted 75.2% of the variance in GLISS ratings, although no association was found between the factor and the percentage of questions. The GLISS and the operationalized measures captured distinct but complementary dimensions of interview structure. Discriminant analysis indicated that, on average, 80% of all interviews were correctly classified as to their type. Our main findings confirm that we can now accurately measure the degree of interview structure. Further research is needed to examine how these measures apply to other interview settings, such as psychoanalytic or cognitive-behavioral treatments, in the social sciences.