Supportive-expressive dynamic psychotherapy in the community mental health system: A pilot effectiveness trial for the treatment of depression

The goal of the current article is to present the results of a randomized pilot investigation of a brief dynamic psychotherapy compared with treatment-as-usual (TAU) in the treatment of moderate-to-severe depression in the community mental health system. Forty patients seeking services for moderate-to-severe depression in the community mental health system were randomized to 12 weeks of psychotherapy, with either a community therapist trained in brief dynamic psychotherapy or a TAU therapist. Results indicated that blind judges could discriminate the dynamic sessions from the TAU sessions on adherence to dynamic interventions. The results indicate moderate-to-large effect sizes in favor of the dynamic psychotherapy over the TAU therapy in the treatment of depression. The Behavior and Symptom Identification Scale-24 showed that 50% of patients treated with dynamic therapy moved into a normative range compared with only 29% of patients treated with TAU. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

The re-establishment of trust through psychotherapy

In the course of life's experiences mistrust develops in childhood and adulthood. Clinical manifestations of mistrustfulness in patients are discussed. Successful psychotherapy has as one of its principal goals the re-establishment of trust within the patient. This takes place through the development of trust toward the therapist. This experience serves as a bridge to the re-establishment of trust in others. Those personal qualities in the therapist which are of the greatest importance in this area are reliability and realistic hopefulness. Being taken seriously and the opportunity to attach to the therapist are also very significant. The place of the therapist's interventions as well as the relevant significant qualities in the patient are also discussed. Trust breeds trust, connection with others and, thence personal security. This is a basic goal of psychotherapy.     

The different kinds of group psychotherapy with patients with different diagnoses

Group psychotherapy is a treatment method in which in addition to the therapist(s) the participating individuals are, autocentrically, active in attaining a therapeutic effect. The different kinds of group psychotherapy are described: 1) activity group psychotherapy, 2) analytic group psychotherapy, 3) directive-suggestive-group psychotherapy, 4) psychodrama, 5) accelerating/focal methods of group psychotherapy. Group psychotherapeutic techniques with patients of different diagnoses are discussed, e.g. group psychotherapy with drug dependants and alcoholics, in which it is not possible to use a pure analytic method of group psychotherapy. Their oral tendencies and narcissistic desires of undergoing a fusion with the therapist have to a certain degree to be fulfilled. Schizophrenics should encounter in group psychotherapy an unconditioned emotional response from the therapist. These patients on the one hand expect to be understood in their psychotic experience, but on the other hand they seem to be glad when the measures of the outside reality are maintained in the group. The relatives of schizophrenics wanting to co-operate are taken in a parallel group. Depressives, especially endogenous depressives, need a longer time to be integrated in a therapeutic group than other patients, but if they can be integrated, it helps them to tolerate their sufferings. To the neurotics, group psychotherapy offers insight and a chance to “translate” this insight into a new social behaviour. Analytic self-experience groups with staff members give them an opportunity to recognise from their own experience the conflicts and the behaviour patterns from which their patients suffer.     

Computer-mediated psychotherapy: toward patient-selection guidelines

The greatest obstacle currently slowing the progress of research in computer-mediated psychotherapy is the fact that unless the physicians using it truly believe in its effectiveness, even the most sophisticated computer technology will fail. The more complex the tasks, the less likely are people, including mental health professionals, willing to believe that computers can successfully carry them out. Many people fear the psychotherapy experience would be dehumanized by the introduction of computer technology. But the medium must not be confused with the message; the computer is simply an extension of the therapist, permitting one therapist to treat not just a few, but thousands of desperate patients. The current state of computer-mediated psychotherapy is such that this medium appears to be best suited to individual psychotherapy of a brief or focused nature, particularly the cognitive-behavioral therapies. The introduction of computer technology into psychotherapy offers the significant advantages of flexibility, consistency, and economy that would make psychotherapy more effective and more readily available to a much broader patient population than the one presently benefiting from such treatment. The preceding discussion has been an attempt to offer some practical guidelines for patient selection for computer-mediated psychotherapy based upon available investigations. As such, it is nevertheless incomplete and open to future revision. Considerable work remains to be done before definitive recommendations can be made, but it is hoped that these suggestions may prove helpful to clinicians working at the frontier of this new and exciting therapeutic medium.     

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.     

Paradox as Symptom in the Borderline Patient's Struggle for Self-Differentiation

Topic. Paradox as symptom in patients diagnosed with borderline personality disorder (BPD).
Purpose. To conceptualize the nature of difficulties arising in psychotherapy with patients diagnosed with BPD.
Sources. Review of the literature and clinical data from the author's work.
Conclusions. The borderline dilemma is inherently paradoxical and, in some ways, reflects the human condition. Psychoanalytic concepts can further our understanding of the therapeutic difficulties encountered in the struggle to make sense of life's inherent dualities. The borderline patient is acutely sensitive to these dualities, which the therapist must tolerate and understand. Often, a negative therapeutic reaction may impede progress.     

Mentalizing in the psychotherapy of a disturbed adolescent girl

The author traces some of the literature related to such concepts as the development of the therapeutic alliance and collaboration in the inpatient and residential psychiatric treatment of disturbed adolescents. The more recently developed concept of "mentalization" is discussed, especially with its relevance to the psychotherapy of difficult-to-treat adolescent patients. A case presentation highlights the establishment of relatedness and trust with such a patient. The case is described in terms of the mental activities of both therapist and patient that facilitated the psychotherapy process in a number of ways. Mentalization is seen as a useful concept, both in terms of understanding the process of psychotherapy, and as a fundamental attribute of the mental activities of the therapist and, likewise, fostered in the patient.     

Group psychotherapy with acting-out patients: specific problems and technique

Severe crises bring acting-out patients to psychotherapy. In order to keep them in treatment, the therapist has to educate them about what psychotherapy is. An explanation of the tasks of psychotherapy, as well as of patient and psychotherapist is required. Factors unique to these patients have to be taken into account. The author's experience demonstrates that group psychotherapy is preferable to individual therapy. Case examples are cited.     

Psychotherapy of borderline patients: the influence of theory on technique.

Although the treatment of borderline patients has attracted increased attention, there is little agreement on the basic nature of the disorder or the proper techniques for its treatment by analytically oriented psychotherapy. The author states that treatment based on the idea that the borderline patient achieves therapeutic gains by raging against an accepting therapist for a prolonged period of time is not so effective as treatment based on the recognition of specific ego defects as the core pathology. He suggests that the therapist be active in the treatment of borderline patients and not permit gross and unproductive distortions of the therapeutic relationship.     

When the patient doesn't die

Little has been written about the effects on psychotherapy when a patient who is expected to die survives. A young woman who was nearing the end of routine psychotherapy was found to have breast cancer. There were two recurrences of the malignancy, and while everything pointed toward a rapid death, the patient did not die. Psychotherapy, which had begun before the diagnosis, continued during intensive medical treatment and beyond. Some of the changes affecting both the patient and the therapist are described, and some guidelines are suggested for conducting psychotherapy with cancer patients who have prolonged survival.     

Sexual minority reflections on their psychotherapy experiences

Objective: Sexual minority (lesbian, gay, bisexual, queer) individuals are regular consumers of psychotherapy, and are more likely to utilize psychotherapy than heterosexually identified individuals. However, there is scant research on sexual minority clients examining their perceptions of therapists’ efforts to work successfully with them. Method: We examined the experiences reported by sexual minority individuals in psychotherapy (N?=?77), utilizing an Internet-based survey that asked open-ended questions such as, “How did your therapist address your sexual orientation?” Result: Using directed content analysis, we derived 19 repeating ideas, which we categorized into five major themes and two overarching concepts, including: (a) participants reported appreciating general person-centered psychotherapy competencies (e.g., active listening, validation, Socratic questioning) and (b) participants reported that various aspects of sexual orientation (e.g., therapist sexual identity, therapist knowledge about sexual minority populations) are relevant to their experiences in therapy and should be addressed directly by therapists. Conclusions: Results indicated that clients want generally competent therapists who understand that a sexual minority identity is only one part of a client's overall identity and not a defining characteristic or psychopathological. We explicate themes and representative quotes, and provide preliminary recommendations for therapists working with sexual minority clients.     

King's Conceptual Model and Individual Psychotherapy

Goal setting is a major component of individual psychotherapy and a concept central to Imogene King's conceptual model of goal attainment. Yet the nursing literature contains no reference to the application of King's model as a framework for conducting individual psychotherapy. Using King's conceptual model, the author describes how the nurse therapist can use the concepts of transactions, interactions, and communication to conduct individual psychotherapy. This author also demonstrates, through use of clinical illustration, the effective application of this nursing model to clinical practice.     

The negative effect of alexithymia on the outcome of group therapy for complicated grief: what role might the therapist play?

Alexithymia is a patient characteristic that reflects deficits in the cognitive processing and regulation of emotions. It is generally considered to have an adverse effect on the outcome of psychotherapy. Little is known about the processes through which alexithymia exerts this effect. One proposed mechanism suggests that patients with alexithymia trigger negative therapist reactions that contribute to poor outcome for such patients. This study examined whether therapist reactions to a patient mediate the relationship between alexithymia and outcome in group psychotherapy for complicated grief. Alexithymia was assessed with the Toronto Alexithymia Scale-20. Therapist reactions to a patient, reflecting the therapist's perceptions of a patient's positive qualities, personal compatibility, and significance as a group member, were assessed with a cohesion questionnaire. Outcome in several areas of functioning was measured. We found that alexithymia (specifically, greater difficulty in communicating feelings and greater tendency to engage in externally oriented thinking) was associated with less favorable outcome and that this relationship was mediated by therapist reactions to a patient. The mediation provided by therapist reactions to a patient accounted for approximately one third to one half of the direct effect of alexithymia on psychotherapy outcome. This suggests that therapist reactions to a patient represent a major mechanism through which alexithymia exerts its effect.     

Boundary violations: a culture-bound syndrome

A backlash against the self-actualizing psychotherapy movements of the 1960s and 1970s in concert with recent concerns about professional sexual misconduct has led some forensic psychiatrists to redefine many routine components of therapy as boundary behaviors. This concern has been followed by the development of conservative guidelines for how therapists should conduct themselves at the newly-defined boundary crossings so as to avoid "violations." The slippery-slope argument that seemingly innocuous boundary crossings may lead inexorably to professional sexual misconduct has lent an urgency and legitimacy to the guideline enterprise, obscuring the perspective that the newly postulated boundaries do not represent the consensus of practitioners in the field. Otherwise highly controversial claims about what is ethical and proper behavior in psychotherapy gain a mantle of incontrovertibility when linked to predictions that ignoring published boundary guidelines will result in damage to patient and litigation against therapist. In this article, three widely advanced boundary guidelines are examined (therapist neutrality, therapist anonymity, and stable fee policy) for coherence and relevance to the richly diverse practice of psychotherapy.     

Goal consensus and collaboration

This article updates our previous article in this journal (Tryon & Winograd, 2001) by examining via meta-analyses results of recent studies, published from 2000 through 2009, that relate goal consensus and collaboration to treatment outcome. Specifically, 15 studies with a total sample size of 1,302 yielded a goal consensus-psychotherapy outcome effect size of .34 (SD = .19, p < .0001, 95% confidence interval = .23-.45), indicating that better outcomes can be expected when patient and therapist agree on therapeutic goals and the processes to achieve these goals. The collaboration-outcome meta-analysis based on 19 studies with a total sample of 2,260 patients yielded a mean correlation of .33 (SD = .17, p < .0001, 95% confidence interval = .25-.42), suggesting that psychotherapy outcome appears to be considerably enhanced when patient and therapist are actively involved in a cooperative relationship. We discuss therapeutic practices that follow from these findings.     

Empirically based guidelines for goal-finding procedures in psychotherapy: Are some goals easier to attain than others?

Abstract Treatment goals are either proposed by a patient or deduced from the case formulation of the therapist. To optimize goal-finding procedures in psychotherapy, therapists need an empirical point of reference to estimate the degree of goal attainment that can be expected for a specific treatment goal. To establish such an empirical basis, treatment goal categories of the primary treatment goals of 2,770 inpatients undergoing cognitive-behavioral therapy were categorized by the Bern Inventory of Treatment Goals. The levels of goal attainment were then compared with respect to 48 different goal categories. The results indicate that goal attainment differs according to treatment goal categories, even if confounding characteristics of the patient are controlled for.     

Measuring Patient Changes in Mood,Anxiety, and Personality Disorders: Toward a Care Battery. Hans H. Strupp,Leonard M. Horowitz,and Michael J. Lambert, (Eds.) Washington,DC: American Psychological Association, (1997)

The construct of transference has been central to theories of dynamic psychotherapy. This investigation evaluated the similarity between patients' interpersonal themes, derived from pretreatment interpersonal interviews, and the theme evident in psychotherapy narratives about the therapist for 18 patients treated in supportive-expressive psychotherapy for major depression. This investigation was designed to sort out the potential confound of the therapist's influence on the report of interpersonal themes and to explore how transference might vary over the course of therapy. The results indicated that 33% of patients demonstrated a significant relation between the most pervasive theme evident from the pretreatment narratives and the narratives about the therapist. These results remained consistent when early and late session therapist narratives were evaluated separately. Further, patients rated with higher quality of interpersonal relationships and lower symptoms prior to treatment demonstrated greater similarity between their pretreatment interpersonal themes and the theme described in the therapeutic relationship.     

Psychoanalytically based psychotherapy in childhood and adolescents from the viewpoint of expert assessment

Depth psychologically founded or analytically psychotherapy with children and adolescents is not only a question of the respective "Fachkunde", a variable referring to the therapist and his training. Aspects of differential indication and effective factors pertaining to psychoanalytic techniques must also be taken into consideration. There are different techniques which should be conceptulized as a continuum. The effective factors vary in their impact. It seems problematic to distinguish between single discrete techniques. Depth psychologically founded psychotherapy with children and adolescents is a technique characterized by a limited goal which can be formulated in a "focus". Special emphasis has to be laid on the environment and the present state of development. First findings from a workshop on focal psychotherapy with children and adolescents at the Psychoanalytischen Institut Bremen, are discussed by case illustration.     

Mental health characteristics of patients assigned to long-term ambulatory psychoanalytic psychotherapy and psychoanalysis in the netherlands

Abstract

Treatment goals are either proposed by a patient or deduced from the case formulation of the therapist. To optimize goal-finding procedures in psychotherapy, therapists need an empirical point of reference to estimate the degree of goal attainment that can be expected for a specific treatment goal. To establish such an empirical basis, treatment goal categories of the primary treatment goals of 2,770 inpatients undergoing cognitive–behavioral therapy were categorized by the Bern Inventory of Treatment Goals. The levels of goal attainment were then compared with respect to 48 different goal categories. The results indicate that goal attainment differs according to treatment goal categories, even if confounding characteristics of the patient are controlled for.