Defense Mechanisms and Treatment Response in Depressed Inpatients.

The study investigated the extent to which defensive functioning and defense mechanisms predict clinically meaningful symptomatic improvement within brief psychodynamic psychotherapy for recurrent and chronic depression in an inpatient setting. Treatment response was defined as a reduction in symptom severity of 46% or higher from the baseline score on the Montgomery-Asberg Depression Rating Scale (MADRS). A subsample of 41 patients (19 responders and 22 non-responders) from an RCT was included. For each case, two sessions (the second and the penultimate) of brief inpatient psychodynamic psychotherapy (a manualized 12-session therapy program developed in Lausanne) were transcribed and then coded using the Defense Mechanism Rating Scales (DMRS) and the Psychotic Defense Mechanism Rating Scales (P-DMRS), an additional scale developed to study psychotic defenses. Results showed that defensive functioning and mature and immature defense changed during psychotherapy and predicted treatment response. Patient's defenses observed throughout therapy also predicted treatment response at 12-month follow-up. The addition of psychotic defenses allows a better prediction of the treatment response. Overall, these results are in line with previous research and provide further validation of defensive functioning as a predictor of outcomes and a mechanism of change in psychotherapy

New, but improved? Comparison between first and revised version of the Helping Alliance questionnaire

There is a consensus in the psychotherapy research field to consider the therapeutic alliance, broadly defined as the mutual collaboration between the therapist and the patient, as a robust and consistent predictor of therapy outcome. There is little agreement, however, on the best way to operationalise and measure it. Several instruments are available, each of them displaying some unique features so that investigators have problems to choose among them on the basis of considerations other than ease of administration, continuity with previous research or availability. One of the early self-report measures and widely used instruments was the Helping Alliance questionnaire (HAq-I) (Alexander and Luborsky, 1986). In recent years, we have become aware that it was limited by the presence of items that were explicitly assessing early symptomatic improvement and by the fact that all the items were worded positively. A revised version (HAq-II) was developed (Luborsky et al., 1996), guided by two main goals: (1) to reduce the inclination of the scale toward measuring early symptomatic improvement and thus confusing these two dimensions, and (2) to better incorporate the various aspects of the alliance related to the collaborative effort of patient and therapist. The new instrument includes 5 from the 11 items of the HAq-I and 14 new items - 5 of them worded negatively. The aim of the study is twofold: to validate the French version of the new HAq-II and to investigate empirically to what extent the HAq-II has improved over the HAq-I. The sample included 60 self-referred outpatients assigned to a Brief Psychodynamic Investigation (BPI), a manual-based investigation procedure in four sessions guided by psychodynamic principles. We looked at the correlation between the two HAq (I and II) and the Working Alliance Inventory (WAI), patient pretreatment characteristics (SCL-90, HDRS, HAMA, IIP) and outcome (SCL-90, SAS and patient satisfaction). Results showed that the French version of the HAq-II has good psychometric properties. Estimates of internal consistency and test-retest reliability were fairly similar to the original English version. Indication of its validity included high correlation with other alliance measures and independence from patient pretreatment characteristics. Surprisingly, HAq-II score predicted patient's satisfaction with the treatment but not symptomatic improvement. Taken together, these first results are promising and indicate that the translated version of the HAq-II is a valid instrument for measuring the helping alliance. Concerning the comparison between the two versions of the HAq, HAq-II has proved to be an improvement compared to the original HAq-I scale: it better relates to the alliance construct and it is less influenced by the symptoms of the patient. Considering also its better construct validity (Luborsky et al., 1996), we definitely recommend the use of the revised HAq-II instead of the initial version of the scale. (PsycINFO Database Record (c) 2006 APA, all rights reserved

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: Results of a randomized controlled trial.

For severe and chronic depression, inpatient treatment may be necessary. Current guidelines recommend combined psychological and pharmacological treatments for moderate to severe depression. Results for positive effects of combined treatment for depressed inpatients are still ambiguous. This randomised controlled trial examined the efficacy of adding an intensive and brief psychodynamic psychotherapy (IBPP) to treatment-as-usual (TAU) for inpatients with DSM-IV major depressive episode. The primary outcomes were reduction in depression severity, and response and remission rates at post-treatment, 3-month and 12-month follow-up points. A linear mixed model analysis (N=149) showed a higher reduction in the observer-rated severity of depressive symptoms at each follow-up point for the IBPP condition compared with the TAU condition (post-treatment ES=0.39, 95%CI 0.06-0.71; 3-month ES=0.46, 95%CI 0.14-0.78; 12-month ES=0.32, 95%CI 0.01-0.64). Response rate was superior in the IBPP group compared with the TAU group at all follow-up points (post-treatment OR =2.69, 95%CI 1.18-6.11; 3-month OR=3.47, 95%CI 1.47-8.25; 12-month OR=2.26, 95%CI 1.02-4.97). IBPP patients were more likely to be remitted 3 months (OR=2.82, 95%CI 1.12-7.10) and 12 months (OR=2.93, 95%CI 1.12-7.68) after discharge than TAU patients. Heterogeneous sample with different subtypes of depression and comorbidity. IBPP decreased observer-rated depression severity up to 12 months after the end of treatment. IBPP demonstrated immediate and distant treatment responses as well as substantial remissions at follow-up. IBPP appears to be a valuable adjunct in the treatment of depressed inpatients

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

One minute of grief: Emotional processing in short-term dynamic psychotherapy for adjustment disorder.

OBJECTIVE: Depth of emotional processing has shown to be related to outcome across approaches to psychotherapy. Moreover, a specific emotional sequence has been postulated and tested in several studies on experiential psychotherapy (Pascual-Leone & Greenberg, 2007). This process-outcome study aims at reproducing the sequential model of emotional processing in psychodynamic psychotherapy for adjustment disorder and linking these variables with ultimate therapeutic outcome. METHOD: In this study, 32 patients underwent short-term dynamic psychotherapy. On the basis of reliable clinical change statistics, a subgroup (n = 16) presented with good outcome and another subgroup (n = 16) had a poor outcome in the end of treatment. The strongest alliance session of each case was rated using the observer-rated system Classification of Affective Meaning States. Reliability coefficients for the measure were excellent (κ = .82). RESULTS: Using 1 min as the fine-grained unit of analysis, results showed that the experience of fundamentally adaptive grief was more common in the in-session process of patients with good outcome, compared with those with poor outcomes (χ2 = 6.56, p = .01, d = 1.23). This variable alone predicted 19% of the change in depressive symptoms as measured by the Beck Depression Inventory at the end of treatment. Moreover, sequences of the original model were supported and related to outcome. CONCLUSIONS: These results are discussed within the framework of the sequential model of emotional processing and its possible relevance for psychodynamic psychotherapy. (PsycINFO Database Record (c) 2015 APA, all rights reserved)

The role of cognitive biases in short-term psychodynamic psychotherapy.

The concept of biased thinking - or cognitive biases - is relevant to psychotherapy research and clinical conceptualization, beyond cognitive theories. The present naturalistic study aimed to examine the changes in biased thinking over the course of a short-term dynamic psychotherapy (STDP) and to discover potential links between these changes and symptomatic improvement. This study focuses on 32 self-referred patients consulting for Adjustment Disorder according to DSM-IV-TR. The therapists were experienced psychodynamically oriented psychiatrists and psychotherapists. Coding of cognitive biases (using the Cognitive Errors Rating Scale; CERS) was made by external raters based on transcripts of interviews of psychotherapy; the reliability of these ratings on a randomly chosen 24% of all sessions was established. Based on the Symptom Check List SCL-90-R given before and after, the Reliable Change Index (RCI) was used. The assessment of cognitive errors was done at three time points: early (session 4-7), mid-treatment (session 12-17), and close to the end (after session 20) of the treatment. The results showed that the total frequency of cognitive biases was stable over time (p = .20), which was true both for positive and for negative cognitive biases. In exploring the three main subscales of the CERS, we found a decrease in selective abstraction (p = .02) and an increase in personalization (p = .05). A significant link between RCI scores (outcome) and frequency of positive cognitive biases was found, suggesting that biases towards the positive might have a protective function in psychotherapy. Therapists may be attentive to changes in biased thinking across short-term dynamic psychotherapy for adjustment disorder. Therapists may foster the emergence of positive cognitive biases at mid-treatment for adjustment disorder

Early change in coping strategies in responsive treatments for borderline personality disorder: A mediation analysis.

Difficulty in emotion regulation is a hallmark feature of patients with borderline personality disorder (BPD). Therefore, change in the frequency of certain patients' coping strategies-aiming at emotion regulation-are among the most promising mechanisms of change in treatments for BPD. In parallel, it was highlighted that therapist responsiveness significantly contributed to outcome across treatment approaches (Stiles, 2009). Based on a randomized controlled trial (Kramer et al., 2014), the present process-outcome mediation analysis aims at examining the patient's early change in frequency of coping strategies-in particular the decrease in behavioral forms of coping-as potential mechanism of change in responsive treatments for BPD. A total of 57 patients with BPD were included in the present analysis, out of whom 27 were randomly assigned to a 10-session psychiatric treatment and 30 to a 10-session psychiatric treatment augmented with the responsive intervention of the motive-oriented therapeutic relationship (Caspar, 2007). The 1st, 5th, and 9th session of each therapy were transcribed and analyzed using the Coping Action Pattern Rating Scale (Perry et al., 2005; 171 sessions analyzed in total), a validated observer-rated method for assessing coping strategies in the therapy process. Psychological distress was assessed using the OQ-45 at intake, after Session 5, and after Session 10. The results confirmed a responsiveness effect associated with the motive-oriented therapeutic relationship and showed a significant decrease in frequency of behavioral forms of coping, F(1, 54) = 3.09, p = .05, d = .56, which was not different between the 2 conditions. In addition, we demonstrated that the early decrease in behavioral forms of coping between Sessions 1 and 5 partially mediated the link between the group assignment and the change in psychological distress between Sessions 5 and 10. These results shed light on the centrality of therapist responsiveness in treatments for BPD and its impact on very early change in patient's in-session behavioral coping strategies, contributing to the effectiveness of short-term treatments for BPD. (PsycINFO Database Recor

Adaptation of the Motive-Oriented Therapeutic Relationship Scale to Group Setting in Dialectical-Behaviour Therapy for Borderline Personality Disorder

The therapeutic relationship as a process is usually studied in individual therapy, and less in group therapy. One reason for this paucity of research may be the complex methodology necessary to do process research on group therapy. One of the therapeutic approaches using the group as part of the therapy is dialectical behavior therapy (DBT) for borderline personality disorder (BPD). The purpose of the present study is to develop a group version of a process measure that has been successfully used in individual therapy, the Motive-Oriented Therapeutic Relationship (MOTR) scale, based on individualized case conceptualizations using the Plan Analysis approach. To do this, 10 sessions of a DBT skills group therapy were analyzed from a comprehensive dataset within a randomized controlled trial. Included were therapy completers: 3 patients and 2 therapists. The therapists were unaware of MOTR. The results revealed that the adaptation of the MOTR to DBT skills group was feasible. Its adaptation showed differences of the therapists in their use of MOTR when comparing the different patients: Therapist presented with higher degrees of MOTR toward 1 patient, compared to another. Overall results suggest that effective therapists in DBT skills training intervene with rather low mean levels of MOTR, and great intrasession variability of MOTR. We conclude that the adaptation of the MOTR-instrument to group therapy is feasible and yields meaningful results. Therefore, this scale may be used in process research in group therapy, in particular when 1 wishes to have an individualized measure of the therapeutic relationship

Dialectical behavior therapy skills training affects defense mechanisms in borderline personality disorder: An integrative approach of mechanisms in psychotherapy.

Objective: Borderline personality disorder (BPD) is characterized by immature defense mechanisms. Dialectical behavior therapy (DBT) is an effective treatment for BPD. However, understanding the underlying mechanisms of change is still limited. Using a transtheoretical framework, we investigated the effect of DBT skills training on defense mechanisms. Method: In this randomized controlled trial, 16 of 31 BPD outpatients received DBT skills training adjunctive to individual treatment as usual (TAU), while the remaining 15 received only individual TAU. Pre-post changes of defense mechanisms, assessed with the Defense Mechanism Rating Scale, were compared between treatment conditions using ANCOVAs. Partial correlations and linear regressions were conducted to explore associations between defenses and symptom outcome. Results: Overall defense function improved significantly more in the skills training condition (F(1, 28) = 4.57, p = .041). Borderline defenses decreased throughout skills training, but not throughout TAU only (F(1, 28) = 5.09, p = .032). In the skills training condition, an increase in narcissistic defenses was associated with higher symptom scores at discharge (β = 0.58, p = .02). Conclusions: Although DBT does not explicitly target defense mechanisms, skills training may have favorable effects on defense function in BPD. Our findings contribute to an integrative understanding of mechanisms of change in BPD psychotherapy