Core interpersonal patterns in complex trauma and the process of change in psychodynamic therapy : a case comparison study

We performed a case comparison study to investigate the nature of interpersonal patterns in childhood trauma and the process of change therein. We analyzed three matching cases of childhood trauma that followed a psychodynamic treatment via a mixed-methods design. We found that (1) the core tendency to avoid negative reactions from others through passive behaviors emerged in all three cases, both in childhood and adulthood, (2) core interpersonal patterns transpired in the interaction between patient and therapist and thereby affected the therapeutic relationship, and (3) change ensued when a repetition of core interpersonal patterns was avoided and a new relational experience occurred. The accumulated findings across cases further resulted in several clinical implications and recommendations, such as the importance of the assessment of patients' (covert) conditions, responsiveness, supervision and facilitating patients' agency, and provided several avenues for further research

The influence of interpersonal patterns on the therapy process in a case of childhood trauma

Research concerning the influence of core interpersonal patterns related to childhood trauma on the therapeutic process is scarce. We investigated interpersonal patterns at the start of treatment, changes in interpersonal patterns as treatment progressed, and the change process in a mixed-methods single case study of a supportive-expressive psychodynamic psychotherapy with a 33-year-old female with a history of childhood trauma. The patient showed a pervasive inability to open up towards others throughout the entire treatment, which is closely associated with others' actual or anticipated rejection, disrespect and disinterest. Excessive use of expressive interventions, which target interpersonal change, initially led to a worsening of the patient's condition. Via supportive and general interventions, symptom stabilization was achieved. The findings of this study suggest a thorough understanding of dominant interpersonal patterns is necessary to recognize their influence on the therapy process

Countertransference processes in psychodynamic therapy with dependent (anaclitic) depressed patients : a qualitative study using supervision data

Although Blatt’s two-polarity model of depression has suggested that patients’ interpersonal styles may shape countertransference phenomena in psychotherapy, empirical research on this topic has remained scarce. This article provides an in-depth study of countertransference processes in clinical work with dependent (anaclitic) depressed patients using a qualitative methodology. Thematic analysis of narrative material of psychodynamic therapists discussing patient cases during supervision (n = 7) resulted in four recurrent themes: “empathy, compassion, and support,” “anxiety, feeling overwhelmed, and protection,” “frustration, irritation, and confrontation,” and “inadequacy, incompetence, and fatalism.” We found that these countertransference processes mainly revolved around perceived adaptive and maladaptive aspects of patients’ relational functioning. Regarding clinical practice, our study suggests that therapists can use countertransference to determine in which position they are maneuvered by patients, although we caution against the exclusive use of subjectively informed data as a benchmark in the diagnostic and treatment process. We conclude that further in-depth research on countertransference and personality styles is needed to identify pitfalls in the treatment of depression

No change? A grounded theory analysis of depressed patients' perspectives on non-improvement in psychotherapy

Aim: Understanding the effects of psychotherapy is a crucial concern for both research and clinical practice, especially when outcome tends to be negative. Yet, while outcome is predominantly evaluated by means of quantitative pre-post outcome questionnaires, it remains unclear what this actually means for patients in their daily lives. To explore this meaning, it is imperative to combine treatment evaluation with quantitative and qualitative outcome measures. This study investigates the phenomenon of non-improvement in psychotherapy, by complementing quantitative pre-post outcome scores that indicate no reliable change in depression symptoms with a qualitative inquiry of patients' perspectives.Methods: The study took place in the context of a Randomised Controlled Trial evaluating time-limited psychodynamic and cognitive behavioral therapy for major depression. A mixed methods study was conducted including patients' pre-post outcome scores on the BDI-II-NL and post treatment Client Change Interviews. Nineteen patients whose data showed no reliable change in depression symptoms were selected. A grounded theory analysis was conducted on the transcripts of patients' interviews.Findings: From the patients' perspective, non-improvement can be understood as being stuck between knowing versus doing, resulting in a stalemate. Positive changes (mental stability, personal strength, and insight) were stimulated by therapy offering moments of self-reflection and guidance, the benevolent therapist approach and the context as important motivations. Remaining issues (ambition to change but inability to do so) were attributed to the therapy hitting its limits, patients' resistance and impossibility and the context as a source of distress. “No change” in outcome scores therefore seems to involve a “partial change” when considering the patients' perspectives.Conclusion: The study shows the value of integrating qualitative first-person analyses into standard quantitative outcome evaluation and particularly for understanding the phenomenon of non-improvement. It argues for more multi-method and multi-perspective research to gain a better understanding of (negative) outcome and treatment effects. Implications for both research and practice are discussed

The Ghent Psychotherapy Study (GPS) on the differential efficacy of supportive-expressive and cognitive behavioral interventions in dependent and self-critical depressive patients : study protocol for a randomized controlled trial

Background: Major depressive disorder is a leading cause of disease burden worldwide, indicating the importance of effective therapies. Outcome studies have shown overall efficacy of different types of psychotherapy across groups, yet large variability within groups. Although patient characteristics are considered crucial in understanding outcome, they have received limited research attention. This trial aims at investigating the interaction between therapeutic approach (pre-structured versus explorative) and the personality style of patients (dependent versus self-critical), which is considered a core underlying dimension of depressive pathology. Methods/design: This study is a pragmatic stratified (dependent and self-critical patients) parallel trial with equal randomization (allocation 1: 1) conducted in Flanders, Belgium. One hundred and four patients will be recruited and randomized to either 16-20 sessions of cognitive behavioral therapy for depression (pre-structured approach) or 16-20 sessions of short-term psychodynamic psychotherapy for depression (explorative approach) conducted by trained psychotherapists in private practices. The primary outcome is the severity of depression as measured by the Hamilton Rating Scale for Depression at completion of therapy. Secondary outcome measures include self-reported depressive and other symptoms, interpersonal functioning, idiosyncratic complaints, and the presence of the diagnosis of depression. Additional measures include biological measures, narrative material (sessions, interviews), and health care costs. Discussion: This trial presents the test of an often-described, yet hardly investigated interaction between important personality dimensions and therapeutic approach in the treatment of depression. Results could inform therapists on how to match psychotherapeutic treatments to specific personality characteristics of their patients

Truly false memories: does what happened really matter?

From the moment conceptualizations of trauma-related suffering were introduced, questions arose about the authenticity of memories and symptoms (Herman, 1995). Even now, questions are being asked about the accuracy of traumatic memories, especially in case of borderline personality disorder, with a distinction between believers (recovered memory movement) and non-believers (false memory movement) (Verhaeghe, 2004). This instigated enormous research efforts to shed light on the nature of trauma-related memories. Starting from myriad points of view, trauma is considered as an experience that cannot be represented mentally, that floods people’s coping possibilities (Shapiro & Laliotis, 2011; Van der Kolk & Fisler, 1995). For example, recent neuroimaging studies showed a disruption between affective and linguistic processing systems supporting the suggestion of an inherently non-verbal nature of traumatic memories (Peres, McFarlane, Nasello, & Moores, 2008). Furthermore, it has been found that traumatic memories are rather re-experienced than narrated in comparison to regular auto-biographical memories (Ehlers et al., 2004), that they are more hic et nunc (Michael et al., 2005) and more affect-laden (Van der Kolk et al., 1996). Therefore, emphasis in treating trauma-related symptoms is often laid on being able to verbalize and mentalize the traumatic experience (Shapiro & Laliotis, 2011; Peres et al., 2008). Jones, Harvey and Brewin (2007) found, however, that recovery of trauma was not related to gaining more organized trauma-related memories. From a psychoanalytical point of view, emphasis should not lie on constructing a more coherent trauma-narrative. We argue that memories of every individual are coloured by the subject’s psychological architecture and that the recollections of trauma-patients are probably more accurate – i.e. a more veritable and literal print of the event - because of the fundamental breach with the Symbolic-Imaginary structure. For some, the non-verbal and affective nature of remembering trauma is a sign of “purity”, of a “truth” beyond words, because the transformation - or even distortion - of the events, which always takes place when trying to create a representation of an occurrence, remains absent. However, because people often suffer from the intrusive and repetitive features characterizing recollections of trauma, in psychoanalytic therapy emphasis is placed on the discourse of the patient, embedding the traumatic experience in an individually tailored narrative (i.e. systemic truth, Floury, 2010), in which accuracy of the facts with regard to what “really” took place in the traumatic event (i.e. specular truth, Floury, 2010) and coherency of the created narrative are of minimum concern. In this presentation we will give special attention to the phenomenon of dissociation, in which recollection is missing all together. We will argue that in the brutal confrontation with the Real, the subject defends himself by ‘splitting’ – i.e. a division between what can an cannot be consciously recollected. We will present case material to illustrate how dissociation is embedded in the subject’s psychological structure (i.e. the junction between the Real, the Imaginary and the Symbolic) and the way in which false memories within the dissociative episodes form a defensive framework for the reality of the traumatic experiences the subject encountered

Interpersonal features in complex trauma etiology, consequences, and treatment : a literature review

Complex trauma is a much-debated construct and research findings are dispersed due to, for example, the lack of conceptual clarity about the core features constituting complex trauma and its sequalae. Recently, there has been a vast expansion of research studies on interpersonal features, which is fundamental in understanding complex trauma. The aim of this article is to provide a comprehensive overview of the literature with regard to this dimension. We found that trauma research stresses the importance of interpersonal features on three major levels. First, complex trauma is an umbrella term encompassing prolonged and repeated harmful events that typically occur in the interpersonal sphere. A second line of research focuses on the interpersonal difficulties associated with complex trauma, which can be broadly divided into two related categories: behavioral disruptions and distorted interpersonal schemata. Third, researchers address the importance of interpersonal difficulties in the treatment of complex trauma, especially the formation of the therapeutic alliance. Our literature review reveals that these three research areas are interconnected through the concept of core interpersonal schemata. We proclaim that further research should aim at a deeper understanding of the nature of these interpersonal schemata, the ways they develop, and the processes through which they can change