Oncology Clinicians' Defenses and Adherence to Communication Skills Training with Simulated Patients: an Exploratory Study

The aim of this exploratory study was to assess the impact of clinicians' defense mechanisms—defined as self-protective psychological mechanisms triggered by the affective load of the encounter with the patient—on adherence to a communication skills training (CST). The population consisted of oncology clinicians (N = 31) who participated in a CST. An interview with simulated cancer patients was recorded prior and 6months after CST. Defenses were measured before and after CST and correlated with a prototype of an ideally conducted interview based on the criteria of CST-teachers. Clinicians who used more adaptive defense mechanisms showed better adherence to communication skills after CST than clinicians with less adaptive defenses (F(1, 29) = 5.26, p = 0.03, d = 0.42). Improvement in communication skills after CST seems to depend on the initial levels of defenses of the clinician prior to CST. Implications for practice and training are discussed. Communication has been recognized as a central element of cancer care [1]. Ineffective communication may contribute to patients' confusion, uncertainty, and increased difficulty in asking questions, expressing feelings, and understanding information [2, 3], and may also contribute to clinicians' lack of job satisfaction and emotional burnout [4]. Therefore, communication skills trainings (CST) for oncology clinicians have been widely developed over the last decade. These trainings should increase the skills of clinicians to respond to the patient's needs, and enhance an adequate encounter with the patient with efficient exchange of information [5]. While CSTs show a great diversity with regard to their pedagogic approaches [6, 7], the main elements of CST consist of (1) role play between participants, (2) analysis of videotaped interviews with simulated patients, and (3) interactive case discussion provided by participants. As recently stated in a consensus paper [8], CSTs need to be taught in small groups (up to 10-12 participants) and have a minimal duration of at least 3days in order to be effective. Several systematic reviews evaluated the impact of CST on clinicians' communication skills [9-11]. Effectiveness of CST can be assessed by two main approaches: participant-based and patient-based outcomes. Measures can be self-reported, but, according to Gysels et al. [10], behavioral assessment of patient-physician interviews [12] is the most objective and reliable method for measuring change after training. Based on 22 studies on participants' outcomes, Merckaert et al. [9] reported an increase of communication skills and participants' satisfaction with training and changes in attitudes and beliefs. The evaluation of CST remains a challenging task and variables mediating skills improvement remain unidentified. We recently thus conducted a study evaluating the impact of CST on clinicians' defenses by comparing the evolution of defenses of clinicians participating in CST with defenses of a control group without training [13]. Defenses are unconscious psychological processes which protect from anxiety or distress. Therefore, they contribute to the individual's adaptation to stress [14]. Perry refers to the term "defensive functioning” to indicate the degree of adaptation linked to the use of a range of specific defenses by an individual, ranging from low defensive functioning when he or she tends to use generally less adaptive defenses (such as projection, denial, or acting out) to high defensive functioning when he or she tends to use generally more adaptive defenses (such as altruism, intellectualization, or introspection) [15, 16]. Although several authors have addressed the emotional difficulties of oncology clinicians when facing patients and their need to preserve themselves [7, 17, 18], no research has yet been conducted on the defenses of clinicians. For example, repeated use of less adaptive defenses, such as denial, may allow the clinician to avoid or reduce distress, but it also diminishes his ability to respond to the patient's emotions, to identify and to respond adequately to his needs, and to foster the therapeutic alliance. Results of the above-mentioned study [13] showed two groups of clinicians: one with a higher defensive functioning and one with a lower defensive functioning prior to CST. After the training, a difference in defensive functioning between clinicians who participated in CST and clinicians of the control group was only showed for clinicians with a higher defensive functioning. Some clinicians may therefore be more responsive to CST than others. To further address this issue, the present study aimed to evaluate the relationship between the level of adherence to an "ideally conducted interview”, as defined by the teachers of the CST, and the level of the clinician' defensive functioning. We hypothesized that, after CST, clinicians with a higher defensive functioning show a greater adherence to the "ideally conducted interview” than clinicians with a lower defensive functionin

Change in emotional processing in daily life: relationship with in-session self-esteem

In-session emotional processing is a central component of psychotherapy, but little is known about the types and the quality of emotional processing individuals engage in daily life. An ecological momentary assessment (EMA) schedule has been validated to assess distinct emotional experiences as they emerge in daily life. It remains an open question whether changes observed in distinct emotional experiences over a week of assessment are related to in-session self-esteem. In total, N = 42 university students participated in a one-week assessment of emotions using ecological momentary assessment, as well as in a one-session experiential task of resolving self-criticism (using a two-chair dialogue from emotion-focused therapy). The emotions in daily life were self-reported by the participants on a regular basis, and self-esteem was assessed three times during the two-chair dialogue. Two-level hierarchical linear models reveal emotional changes in daily life, and in-session self-esteem is introduced as predictor at level 2. In-session self-esteem was correlated with symptom levels. The results showed that changes in primary maladaptive emotions in the one-week assessment were predicted by state and trait components of in-session self-esteem, which took place at the outset of the EMA. Trait-components of self-esteem were linked with the level of symptoms, whereas state-components of self-esteem were not. The present study underscores the importance of extending research from within-session observations of emotional processing towards daily life

Psychodynamic aspects of communication skills training: a pilot study

Goals of work:: Communication between patients and oncology clinicians is a key element of cancer care. Emotionally charged consultations may trigger clinicians' defense mechanisms, protecting them from painful emotions. Defense mechanisms, however, may also hamper the recognition of patients' suffering. This pilot study aims to explore clinicians' defense mechanisms observed in communication skills training (CST). Patients and methods:: A verbatim transcription of videotaped interviews with simulated patients were evaluated before (N = 10) and after CST (N = 10) with the defense mechanism rating scales (DMRS). Main results:: A wide variety of defense mechanisms were observed such as obsessional (e.g. intellectualisation) or disavowal (e.g. denial or projection). Immature defense mechanisms decreased after CST. Conclusions:: A wide variety of defense mechanisms are operant in oncology clinicians facing challenging interviews with simulated patients. Defense mechanisms may be modified by CS

Integrating Core Conflictual Relationship Themes in neurobiological assessment of interpersonal processes in psychotherapy

Interpersonal processes are a key target in counselling and psychotherapy. It is of paramount importance to sharpen their assessment using integrated methods. Hence, this methodological paper describes how fields of research in psychotherapy and neuroimaging can be integrated into one novel complementary neurobehavioural paradigm that can be applied to enhance our understanding of interpersonal processes in psychotherapy. To illustrate this integration, we present selected data from a pre–post pilot study where the authors assessed interpersonal processes in brief treatment for borderline personality disorder using the core conflictual relationship theme, functional magnetic resonance imaging (fMRI) and outcome questionnaires. To do so, they measured individual changes in neural activity using an fMRI task pre‐ and post‐treatment where clients gave feedback on the emotional valence of sentences extracted from their own Relationship Anecdotes Paradigm interviews mixed with neutral ones. In this paper, using data from two participants of said study, we discuss how to implement this methodology and what can be achieved in terms of results

Mechanisms of change in brief treatments for borderline personality disorder: a protocol of a randomized controlled trial

Borderline personality disorder (BPD) is one of the most frequent, most debilitating and lethal mental conditions and is associated with a serious burden of disease. Treatment for patients with BPD involves structured psychotherapy, and may involve brief psychiatric treatment as first-line intervention. No controlled study has assessed the effectiveness of such brief intervention. Whereas most psychotherapy studies in patients with BPD focus on the effectiveness of the intervention, we still lack an understanding of how and why these effects are produced from a patient process perspective. It is therefore of utmost importance to study the treatment-underlying mechanisms of change. The present study plans to apply novel measurement methods for assessing change in two central psychobiological processes in BPD: emotion and socio-cognitive processing. The study uses theory-driven and ecologically valid experimental tasks, which take the patient's individual experience as the anchor, by integrating methodology from psychotherapy process and neurofunctional imagery research. The aim of this two-arm, randomized controlled study is to test the effects (i.e., symptom reduction) and the underlying mechanisms of change associated with a brief psychiatric treatment (10 sessions over 4 months), compared with treatment as usual. Participants (N = 80 patients with BPD) undergo assessments at four points (intake, 2 months, discharge, and 12-month follow up). In addition to symptom measures, individuals undergo a 2-step assessment for the potential mechanisms of change (i.e., emotion and socio-cognitive processing): (1) behavioral and (2) (for a sub-sample) neurofunctional. We hypothesize that change in the mechanisms explains the treatment effects. This study uses an easy-to-implement treatment of BPD, and a sophisticated assessment procedure to demonstrate the critical role of psychobiological change in emotion and socio-cognitive processing in brief treatments. It will help increase the effectiveness of brief treatment for BPD and help diminish the societal burden of disease related to BPD, in these early stages of treatment. TRIAL REGISTRATION {2}: ClinicalTrials.gov: NCT03717818. Registered on 24 October 2018). Protocol version {3} number 2 from 9 February 2018

Ecological momentary assessment of emotional processing: An exploratory analysis comparing daily life and a psychotherapy analogue session

Background: Emotional processing has been studied in psychotherapy as a state-dependent, sequential process of change. So far, no studies have applied this conceptualisation of emotional processing to the assessments of emotion in daily life. This is particularly important in the light of the pertinence of day-by-day fluctuations of emotions for understanding mental health and for monitoring the impact of prevention and psychotherapy programmes. This study examined the internal and ecological validity of a state-dependent conceptualisation of emotional processing in daily life, in comparison with an experiential-psychodynamic psychotherapy analogue session. Methods: In total, N = 42 university students participated in an experiential-psychodynamic session, completed symptom measures and responded to a one-week period of ecological momentary assessment (EMA) using a smartphone. Emotional processing in the session was assessed using the valid observer-rated measure Classification of Affective Meaning States (CAMS), and emotional responses in daily life were assessed using newly developed theory-consistent items self-rated via an interactive smartphone program. Results: Internal validity was generally satisfactory across the subscales used in EMA. Correspondence between EMA and in-session emotional processing was generally low, but specific relationships were found between self-rated fear, rejecting anger, hurt/grief or loneliness and the observer-rated productive emotions in the psychotherapy analogue session. Relationships between maladaptive emotional processing and intensity in symptoms were found. Conclusions: This is the first study to have examined the validity of a state-dependent conception of emotional processing in daily life, in direct comparison with a psychological session. We recommend using this assessment schedule to develop or complement integrative prevention or intervention programmes