Prospective Evaluation of a Circulating Tumor Cell Sensitivity Profile to Predict Response to Cisplatin Chemotherapy in Metastatic Breast Cancer Patients

Background

Cisplatin (cDDP) has regained interest for metastatic breast cancer (MBC) patients, given the platinum sensitivity in subtypes and better manageable toxicity. Here, the primary aim was to determine whether molecular characteristics of circulating tumor cells (CTCs) could identify patients responding to cDDP and to describe the outcomes to cDDP monotherapy in a large group of MBC patients pretreated with anthracycline- and taxane-based treatments.

Methods

Based on cell line data, a CTC-cDDP-sensitivity profile was generated. Applying an A’Herns single-stage phase II design, further investigation was considered worthwhile if 5/10 patients with a favorable profile responded to cDDP. Patients received 70mg/m² cDDP every three weeks, CTCs were enumerated and the CTC-cDDP-sensitivity profile was determined. In total, 65 heavily pretreated MBC patients (77% received ≥2 lines of previous chemotherapy for MBC) were eligible for the per-protocol analysis. Primary endpoint was response rate, secondary endpoints included best observed response, progression-free survival (PFS) and overall survival (OS).

Results

The best observed response during cDDP therapy was a partial response in 7% and stable disease in 56% of the patients. None of the patients with a favorable CTC-cDDP-sensitivity profile had a response. The median baseline CTC count was 8 (range 0-3254). Patients with <5 CTCs had a better PFS and OS than patients with ≥5 CTCs (median PFS 4.5 months (95%CI 2.38-6.62) vs. 2.1 months [(95%CI 1.34-2.80)(p=0.009)] and median OS 13.1 months (95%CI 9.89-16.33) vs. 5.6 months [(95%CI 3.60-7.64)(p=0.003)]. No other factors than CTC count were associated with outcome to cDDP therapy, including triple-negative breast cancer versus ER-positive tumors.

Conclusions

The CTC-cDDP-sensitivity profile was unable to select patients responding to cDDP monotherapy. In an unselected group of heavily pretreated MBC patients, cDDP yields outcomes comparable to other chemotherapeutic regimens for heavily pretreated MBC patients. CTC count was the only factor associated with outcome in these patients.

Clinical Trial Registration

(https://www.trialregister.nl/trial/3885, identifier NTR4046)

Double trouble: Therapists with low facilitative interpersonal skills and without training have low in-session experiential processes

Objectives: This study examined the combined effect of therapist Facilitative Interpersonal Skills (FIS) and Training Status on experiential processes within therapy sessions. In this randomized trial of FIS and Training Status, we predicted that in-session experiential processes would be highest for the high FIS and trained therapist group and lowest for the low FIS and untrained therapists. Methods: Forty-five clients were selected from 2,713 undergraduates using a screening and clinical interview procedure. Twenty-three therapists were selected for their level of FIS (high vs. low) and Training (trainee vs. untrained) and each were assigned two clients for seven sessions each. Two different coder teams independently rated experiencing and narrative process from the third therapy session and computer analysis identified affect words from transcripts. Results: FIS×Training Status significantly interacted on the set of experiential process measures. Relative to all others, therapists who were in the low FIS / no training group had lower experiencing and reflexive content, but higher external content. Conclusions: The findings highlight the importance of therapist characteristics within therapy sessions. Therapists without training and with low interpersonal skills have sessions that are nearly devoid of content that focuses on client experiential processes and emotion.

Getting to "Yes": Overcoming Client Reluctance to Engage in Chair Work

Goals

Securing clients’ active and enthusiastic collaboration to participate in activities therapists would like to implement in therapy (e.g., free association, in vivo exposure, or the engagement in chair work) is a core mission in therapy. However, from the clients’ perspective, these tasks frequently represent novel challenges that can trigger anxiety and reluctance. Thus, a key element in therapy is the negotiation between therapist and client to move beyond such reluctance to potentially effective therapy activities and, at the same time, maintain positive relational affiliation between therapist and client. In this research we examined (1) a collection of therapist proposal/client response sequences that were geared toward recruiting participation in chair work and (2) sequences containing hesitation or instances where decisions to engage in chair work were deferred and related relational disaffiliation. Our goal was to identify the conversational resources (both verbal and non-verbal) that worked to reject a proposed activity (or convey impending rejection) and examine the interactional practices directed at resolving client reluctance.

Method

We used the conceptual and methodological resources of Conversation Analysis to examine a corpus of proposal/response sequences that targeted chair work entry in Emotion-focused Therapy.

Results

The resulting data set included some smooth and successful engagements and others more challenging, involving clients delaying or resisting engagement with chair work. Clients were found to defer or refuse engagement through a range of resources such as withholding a response (silence), questioning the authenticity of the task, or directly refusing. We identified specific therapist practices that facilitated engagement in “refusal-implicative” contexts such as proffering “or” alternatives, offering extended rationales for the activity (accounting), and elaborating on the proposals. We observed that the therapists’ deontic stance (mitigated and reduced claims to authority) and moderated epistemic positioning (deference to the client’s primacy of knowledge and information) played an important role in facilitating engagement.

Conclusion

Our research highlights the kinds of interactional sequences in which clients and therapists are able to achieve alignment in mutually working toward chair work entry. Based on these observations, we offer some practical advice to therapists in formulating proposals to engage clients during in-therapy work.

Responding to self-criticism in psychotherapy

OBJECTIVE

We explored the interactive process in which therapists respond to client self-critical positions.

METHODS

Drawing from the resources of conversation analysis (CA), we examined a corpus of in-session self-critical sequences of talk occurring in different kinds of treatments: Client Centered Therapy, (CCT), Emotion Focused Therapy (EFT), Psychoanalytic Psychotherapy (PP) and in different cultural contexts.

RESULTS

It was found that client self-critical talk performed various functions pertaining to diminished control, accountability (e.g., failed obligations leading to self-blame) and disparaging evaluations of self (contempt or disgust). Further, therapists were found to respond in ways that targeted the client's report of having diminished control or of being accountable for their negative attributes by providing a more optimistic reading of the client's experience, one that is more open to positive outcomes and the possibility of change. Our sequential analysis not only shows how clients may resist these optimistic readings, but also how therapists work towards successfully achieving moments of re-affiliation.

CONCLUSION

We anticipate that the fine-grained sequential analysis of therapy interaction can provide therapists with a more detailed understanding of the options and challenges therapists face when working with clinical challenges of clients' self-critical positions.

Client Accounts of Corrective Experiences in Psychotherapy: Implications for Clinical Practice

The Patient Perceptions of Corrective Experiences in Individual Therapy (PPCEIT; Constantino, Angus, Friedlander, Messer, & Moertl, 2011) posttreatment interview guide was developed to provide clinical researchers with an effective mode of inquiry to identify and further explore clients' firsthand accounts of corrective and transformative therapy experiences and their determinants. Not only do findings from the analysis of client corrective experience (CE) accounts help identify what and how CEs happen in or as a result of psychotherapy, but the measure itself may also provide therapists with an effective tool to further enhance clients' awareness, understanding, and integration of transformative change experiences. Accordingly, we discuss in this afterword to the series the implications for clinical practice arising from (a) the thematic analysis of client CE accounts, drawn from a range of clinical samples and international research programs and (b) the clinical effect of completing the PPCEIT posttreatment interview inquiry. We also identify directions for future clinical training and research.

Patients' Perceptions of Corrective Experiences in Naturalistically Delivered Psychotherapy

Corrective experiences (CEs), which suggest transformative experience(s) for the psychotherapy patient, have a rich theoretical history; yet there is little empirical information on patients' own perceptions of what gets "corrected" from therapy, and what is "corrective" (i.e., the mechanisms driving the CE). To address this gap, we investigated 14 patients' posttreatment accounts of both CE elements in the context of naturalistically delivered individual psychotherapy, using a consensual qualitative research methodology. Extending prior research focused on patients' accounts of CEs while still engaged in treatment (Heatherington et al., 2012), the present results revealed that patients retrospectively identified an array of categories that were deemed corrected, such as positive changes in cognitions, interpersonal problems, self-concepts, symptoms, and behaviors. Patients also identified CEs that may have led to those shifts/transformations, including their therapist's actions (especially giving feedback), their own agentic actions (especially engaging in the therapeutic process), and the patient-therapist collaborative and engaged relationship. Clinical practice implications are discussed.

Clients' Retrospective Accounts of Corrective Experiences in Psychotherapy: An International, Multisite Collaboration

This article introduces a series of 4 original research reports that used varied qualitative methods for understanding an internationally diverse sample of clients' own accounts of corrective experiences (CEs), as they looked back on their completed psychotherapy. The basis for all studies, which were conducted across 4 different countries, was the Patients' Perceptions of Corrective Experiences in Individual Therapy (PPCEIT) semistructured interview protocol (Constantino, Angus, Friedlander, Messer, & Moertl, 2011). The PPCEIT interview assesses clients' retrospective accounts of aspects of self, other, and/or relationships that may have been corrected, and what they perceived as corrective experiences that facilitated such transformations. It also asks for specific, detailed examples of these accounts and experiences. Across all studies, the PPCEIT interview generated rich clinical material and resulting empirically generated themes that may inform clinical practice. After briefly defining the CE construct and highlighting a lack of research on clients' own accounts of such experiences, we describe the development of the PPCEIT interview (and provide the full interview manual and question protocol as appendices). We then summarize the foci of the culturally diverse reports in this series.

Identity and Meaning in the Experience of Cancer

The purpose of this qualitative study was to explore the experiences of three women breast-cancer survivors and the associated experiences of their partners. Individual in-depth interviews were conducted using a narrative approach, and the six accounts were analysed using the grounded theory method. The results describe the marked variation in the meaning of the experience among the participants, and the perceived change in each woman’s identity from prior to her cancer diagnosis to the time of the interview. The findings are presented in three sections: (1) Three Narrative Themes, the themes, Back to ‘Normal’, Rebirth and Turning Point, that represent the perceived change in each woman’s identity; (2) The Construction of Meaning, the shared characteristics that relate to meaning construction and identity; (3) Integration, the integration in each self-narrative of past and present self-understandings. The findings are compared with the existing literature, and the implications of different interpretations of self and change in the cancer experience are discussed. The limitations of the study are discussed with recommendations for future research.

"If those tears could talk, what would they say?" Multi-method analysis of a corrective experience in brief dynamic therapy

We analyzed master theorist/therapist Hanna Levenson's six-session work with "Ann" in American Psychological Association's Theories of Psychotherapy video series to determine if and how this client had a corrective experience in Brief Dynamic Therapy. First, we identified indicators of a corrective experience in the therapist's and client's own words. Complementing this analysis, we used observational coding to identify, moment by moment, narrative-emotion markers of shifts in Ann's "same old story"; the frequency, type, and depth of immediacy; and the client's and therapist's behavioral contributions to the working alliance. Additionally, we qualitatively analyzed Levenson's session-by-session accounts of the therapy from two sources. Convergent evidence from these multi-method analyses suggested how the intertwined relational and technical change processes seemed to bring about this client's corrective experience. Through consistent attention to the alliance and increasingly deep immediacy, Levenson created a safe space for Ann to "bring down the wall"-by allowing herself to cry and be deeply understood and cared for in a way that she had never before experienced. Concurrently, Ann began seeing herself quite differently, signified by self-identity narrative change. Then, following Session 4, she took Levenson's suggestion to risk behaving more authentically with a friend and with her romantic partner.

Self-narrative reconstruction in emotion-focused therapy: A preliminary task analysis

OBJECTIVE

This research explored the consolidation phase of emotion-focused therapy (EFT) for depression and studies-through a task-analysis method-how client-therapist dyads evolved from the exploration of the problem to self-narrative reconstruction.

METHOD

Innovative moments (IMs) were used to situate the process of self-narrative reconstruction within sessions, particularly through reconceptualization and performing change IMs. We contrasted the observation of these occurrences with a rational model of self-narrative reconstruction, previously built.

RESULTS

This study presents the rational model and the revised rational-empirical model of the self-narrative reconstruction task in three EFT dyads, suggesting nine steps necessary for task resolution: (1) Explicit recognition of differences in the present and steps in the path of change; (2) Development of a meta-perspective contrast between present self and past self; (3) Amplification of contrast in the self; (4) A positive appreciation of changes is conveyed; (5) Occurrence of feelings of empowerment, competence, and mastery; (6) Reference to difficulties still present; (7) Emphasis on the loss of centrality of the problem; (8) Perception of change as a gradual, developing process; and (9) Reference to projects, experiences of change, or elaboration of new plans.

CONCLUSIONS

Central aspects of therapist activity in facilitating the client's progression along these nine steps are also elaborated.

Humanistic psychotherapy research 1990-2015: from methodological innovation to evidence-supported treatment outcomes and beyond

OBJECTIVE

Over the past 25 years, humanistic psychotherapy (HP) researchers have actively contributed to the development and implementation of innovative practice-informed research measures and coding systems.

METHOD

Qualitative and quantitative research findings, including meta-analyses, support the identification of HP approaches as evidence-based treatments for a variety of psychological conditions.

RESULTS

Implications for future psychotherapy research, training, and practice are discussed in terms of addressing the persistent disjunction between significant HP research productivity and relatively low support for HP approaches in university-based clinical training programs, funding agencies, and government-supported clinical guidelines.

CONCLUSION

Finally, specific recommendations are provided to further enhance and expand the impact of HP research for clinical training programs and the development of treatment guidelines.

Ambivalence in emotion-focused therapy for depression: the maintenance of problematically dominant self-narratives

OBJECTIVE

Ambivalence can be understood as a cyclical movement between an emerging narrative novelty-an Innovative Moment (IM)-and a return to a problematically dominant self-narrative. The return implies that the IM, with its potential for change is devalued right after its emergence. Our goal is to test the hypothesis that the probability of the client expressing such form of ambivalence decreases across treatment in good-outcome cases but not in poor-outcome cases.

METHOD

Return-to-the-Problem Markers (RPMs) signaling moments of devaluation of IMs were coded in passages containing IMs in six clients with major depression treated with emotion-focused therapy: three good-outcome cases and three poor-outcome cases.

RESULTS

The percentage of IMs with RPMs decreased across therapy in good-outcome cases, whereas it remained unchanged and high in the poor-outcome cases.

CONCLUSIONS

These results were consistent with the theoretical suggestion that therapeutic failure may be associated with this form of ambivalence.

Narrative Processes Coding System: A Dialectical Constructivist Approach to Assessing Client Change Processes in Emotion-Focused Therapy of Depression

Drawing on a Dialectical Constructivist model of therapeutic change, this paper addresses the fundamental contributions of client narrative disclosure, emotional differentiation and reflexive meaning-making processes in emotion-focused treatments of depression. An overview of the multi-methodological steps undertaken to empirically investigate the contributions of client storytelling, emotional differentiation, and meaning-making processes, using the Narrative Processes Coding System (NPCS; Angus et al., 1999) are provided, followed by a summary of key research findings that informed the development of a narrative-informed approach to emotion-focused therapy of depression (Angus & Greenberg, 2011). Finally, therapy practice implications for the adoption of a research-informed approach to working with narrative and emotion processes in emotion-focused therapy are described and future research directions discussed.

Client experiences of motivational interviewing for generalized anxiety disorder: a qualitative analysis

While Motivational Interviewing (MI) has demonstrated efficacy, little is known about the mechanisms through which MI achieves beneficial effects or how clients perceive the process of MI. The present study addressed this gap through a qualitative analysis of client accounts following four sessions of MI for generalized anxiety disorder. Clients identified increased motivation for treatment and change, experiencing the therapist as empathic and MI as a safe place to explore their feelings regarding change. MI was also described as deviant from client initial expectations. Overall, the emergent understanding of MI derived from clients' post-treatment narratives was consistent with MI principles and processes.

Developing a Systematic Procedure for the Assessment of Self-Defining Memories in Psychodynamic Therapy: Promise and Pitfalls

The innovative approach to assessing autobiographical memory narratives that Singer and Bonalume (2010) demonstrate in their case study of Cynthia is an ambitious expression of integrative psychotherapy research. It brings together the rich research findings on self-defining memories derived from laboratory studies and therapy case analyses, and applies these to the multimodal assessment situation in a psychotherapy program. Further, Singer and Bonalume's case of Cynthia is grounded in a truly "common factor" that is essential to most if not all psychotherapies: patient narrative expression. However, the integration of findings across different research studies still needs further elaboration to clarify and explore when they are consistent and when they are inconsistent with one another. In our commentary we critically assess the following issues associated with Singer and Bonalume's narrative memory coding system and its application to the case of Cynthia: (a) the utilization of narrative analyses for the identification of themes; (b) challenges inherent in establishing criteria for the identification of clinically important autobiographical memory narratives in therapy sessions; (c) the degree of integrative processing that takes place in narrative expression; and (d) the process of formulating inferences based on client narrative expression in assessment interviews versus therapy sessions.  The commentary concludes with a discussion of promising future directions for narrative research in psychotherapy.  

Maintenance of gains following experiential therapies for depression

Follow-up data across an 18-month period are presented for 43 adults who had been randomly assigned and had responded to short-term client-centered (CC) and emotion-focused (EFT) therapies for major depression. Long-term effects of these short-term therapies were evaluated using relapse rates, number of asymptomatic or minimally symptomatic weeks, survival times across an 18-month follow-up, and group comparisons on self-report indices at 6- and 18-month follow-up among those clients who responded to the acute treatment phase. EFT treatment showed superior effects across 18 months in terms of less depressive relapse and greater number of asymptomatic or minimally symptomatic weeks, and the probability of maintaining treatment gains was significantly more likely in the EFT treatment than in the CC treatment. In addition, follow-up self-report results demonstrated significantly greater effects for EFT clients on reduction of depression and improvement of self-esteem, and there were trends in favor of EFT, in comparison with CC, on reduction of general symptom distress and interpersonal problems. Maintenance of treatment gains following an empathic relational treatment appears to be enhanced by the addition of specific experiential and gestalt-derived emotion-focused interventions. Clinical and theoretical implications of these findings are presented.

Lifetime measurements of the neutron-rich N = 30 isotones 50Ca and 51Sc: orbital dependence of effective charges in the fp shell

The lifetimes of the first excited states of the N = 30 isotones (50)Ca and (51)Sc have been determined using the Recoil Distance Doppler Shift method in combination with the CLARA-PRISMA spectrometers. This is the first time such a method is applied to measure lifetimes of neutron-rich nuclei populated via a multinucleon transfer reaction. This extends the lifetime knowledge beyond the f_{7/2} shell closure and allows us to derive the effective proton and neutron charges in the fp shell near the doubly magic nucleus (48)Ca, using large-scale, shell-model calculations. These results indicate an orbital dependence of the core polarization along the fp shell.

The narrative processes coding system: research applications and implications for psychotherapy practice

The Narrative Processes model is focused on the strategies and processes by which a client and therapist transform the events of everyday life into a meaningful story that both organizes and represents the client's sense of self and others in the world. Some investigators have elected to use clients' within session descriptions of relationship events or micronarratives as their unit of narrative analysis. In contrast, we are centrally interested in the development of the macronarrative framework in which the singular events described in a therapy relationship-micronarratives-come to be articulated, experienced, and linked together in such a way that the client's sense of his or her life story-in essence, the sense of self-may be transformed at the conclusion of the therapeutic relationship. The following paper details the Narrative Processes theory of therapy and the coding system that has been developed to identify and evaluate empirically key components of the model. Findings emerging from the analyses of successful psychotherapy dyads are described and the implications for future research and practice are discussed.

Nerve-derived trophic factors and DNA elements controlling expression of genes encoding synaptic proteins in skeletal muscle fibers

The neuromuscular junction represents an excellent model system for studying various critical issues in neurobiology at the molecular, cellular, and physiological levels. Our understanding of the basic events underlying synpase formation, maintenance, and plasticity has progressed considerably over the last few years primarily because of the numerous studies that have focused on this synapse and used sophisticated recombinant DNA technology. Recent data indicate that myonuclei located in the vicinity of the postsynaptic membrane are in a differential state of transcription compared to nuclei of the extrasynaptic sarcoplasm. Thus, renewal of postsynaptic membrane proteins appears to occur via a mechanism involving the local transcriptional activation of genes encoding these specialized proteins and extracellular cues originating from motoneurons. Such interaction between presynaptic nerve terminals and the postsynaptic sarcoplasm indicates that the entire signal transduction pathway is compartmentalized at the level of the neuromuscular junction. Expression of these genes appears less coregulated than originally anticipated, indicating that maintenance of the postsynaptic membrane requires the contribution of multiple extracellular signals, which ultimately urge target transcription factors to distinct DNA regulatory elements via various second messenger systems.

Complicated urinary infection in spinal injury patients: fleroxacin compared with ciprofloxacin

The efficacy and safety of fleroxacin and ciprofloxacin were evaluated in a single-centre, prospective, randomised, blinded study of patients with complicated urinary infection in a spinal injury unit. Patients were randomised to receive oral fleroxacin 400 mg once daily (n = 68) or oral ciprofloxacin 500 mg twice daily (n = 65) for 10 days. Clinical cure assessed 5-9 days after therapy was obtained in 41 of 42 (98%) assessable patients in the fleroxacin group, and in 41 of 43 (95%) of the ciprofloxacin group, and was maintained at the 6-week follow-up visit in all but 1 patient in each group. Bacteriological eradication rates 5-9 days after therapy exceeded 88% in the fleroxacin group and 86% in the ciprofloxacin group, and 69 and 65%, respectively, 6 weeks after completion of therapy. Adverse events occurred in a similarly low percentage of patients (19 and 20%) in both treatment groups, and consisted primarily of nausea. Once daily fleroxacin appears to be as safe and effective as twice daily ciprofloxacin and both represent efficacious treatment in complicated urinary infection in spinal injury patients.