Helmut Kirchmann

Associations among attachment characteristics, patients’ assessment of therapeutic factors, and treatment outcome following inpatient psychodynamic group psychotherapy

Abstract Within a multisite study, including 289 inpatients from six different hospitals who underwent interpersonal-psychodynamic group psychotherapy, associations among attachment characteristics, therapeutic factors, and treatment outcome were investigated. Attachment characteristics were assessed with an interview-based measure (Adult Attachment Prototype Rating [AAPR]) as well as an attachment self-report (Bielefeld Questionnaire of Client Expectations [BQCE]). Therapeutic factors were measured retrospectively with the Düsseldorf Therapeutic Factors Questionnaire and treated as an individual- as well as a hospital-specific characteristic. On an individual level, only the group climate factor independently predicted treatment outcome (i.e., Symptom Checklist-90-R Global Severity Index and Inventory of Interpersonal Problems mean). If simultaneously but separately included into a path model, analyses revealed independent significant effects of AAPR-Security and BQCE-Security on group climate. If modeled as a latent variable (common attachment security), a substantially higher proportion of group climate variance could be explained. Further analyses revealed interactions between particular therapeutic factors and attachment characteristics, indicating a particular importance of these therapeutic factors for different attachment categories.

Benefits and challenges in practice-oriented psychotherapy research in Germany: The TK and the QS-PSY-BAY projects of quality assurance in outpatient psychotherapy

Abstract Objective: Two patient-focused long-term research projects performed in the German outpatient psychotherapy system are focused on in this article. The TK (Techniker Krankenkasse) project is the first study to evaluate a quality assurance and feedback system with regard to its practical feasibility in German routine care. The other study (“Quality Assurance in Outpatient Psychotherapy in Bavaria”; QS-PSY-BAY) was designed to test a new approach for quality assurance in outpatient psychotherapy using electronic documentation of patient characteristics and outcome parameters. In addition this project provides the opportunity to analyze data on health-related costs for the patients undergoing outpatient psychotherapy. Method: Both projects and their results indicating high effect sizes are briefly described. Results: From the perspectives of the research teams, advisory boards and other stakeholders, the experiences with these projects are discussed focusing on obstacles, challenges, difficulties, and benefits in developing and implementing the studies. The triangle collaboration of therapists, researchers, and health insurance companies/health service institutions turned out to be fruitful in both studies. Conclusions: Despite some controversies between the partners the experiences indicate the importance of practiced-research collaborations to provide relevant information about the delivery of outpatient psychotherapy in the health system.

Effects of adult inpatient group psychotherapy on attachment characteristics: An observational study comparing routine care to an untreated comparison group

Abstract This study investigated the changes in attachment characteristics of patients undergoing inpatient group psychotherapy in routine care. We collected data from 265 consecutively recruited patients and 260 non-clinical control persons using self-report measures of attachment, depression, and socio-demographic characteristics. The effects of treatment on patients were analyzed using propensity score techniques (propensity strata and logit-transformed propensity scores) in combination with a generalized analysis of covariance. A moderate increase of attachment security was found which could be attributed to a decrease both in attachment anxiety and avoidance. Pre-post improvements in attachment with regard to romantic partnerships were stable after a 1-year follow-up. Furthermore, we found significant treatment-covariate interactions indicating that subjects with particularly high treatment propensities (propensities were highly correlated with depression and attachment anxiety) improved the most in terms of attachment security. Our results are encouraging for psychotherapeutic practice in that they provide evidence that long-term attachment improvements can be reached via psychotherapy. Our results will also provide a sound basis for future studies in the field of clinical attachment research, e.g., studies examining whether improved attachment security is correlated to symptom improvements in different psychological disorders.

Changes of attachment status among women with personality disorders undergoing inpatient treatment

Background: Attachment has increasingly received attention in psychotherapy and has been used as a predictor of process and outcome. Studies investigating changes of attachment styles during psychotherapy are very rare. Method: Forty women with either borderline (BPD) or avoidant personality disorders (AVPD), treated as inpatients, were investigated using an attachment interview (interpersonal relations assessment (IRA)), and questionnaires to determine therapy outcome at the beginning and after seven weeks of therapy. The IRA uses similar questions as the adult attachment interview (AAI) and is used as the basis for the adult attachment prototype rating (AAPR), a procedure to assign individuals to prototypical categories of attachment. Results: The study showed that the therapy in general was effective. In contrast to other studies, we did not find many women classified as secure at the end of their therapy. Comparisons of pre-post-ratings revealed instead that clients within both subgroups received higher ratings for the avoidant prototypes at the end of therapy, indicating deactivation of attachment. Changes from ambivalent to avoidant attachment were linked with better outcome among women with borderline personality disorder (BPD). Conclusions: This study adds further evidence to the result that attachment styles do not change dramatically during a time-limited psychological treatment of personality disorder. Instead, the study showed that features of preoccupied/ambivalent attachment were less significant after seven weeks of therapy. For women with BPD, these changes were linked with a more favourable outcome which might reflect a more structured and deactivated attachment status as a result of inpatient therapy.

SCL-90-R Symptom Profile Clusters among Inpatients Undergoing Psychodynamic Group Psychotherapy: Cluster Stability, Associations with Clinical Characteristics and Treatment Outcome

Background/Aims: Based on pretreatment psychopathological symptoms measured with the Symptom Checklist 90 Revised (SCL-90-R), this study investigated whether stable symptom clusters exist among psychotherapy inpatients. Furthermore, it was examined whether the identified clusters would differ with respect to clinical characteristics and treatment outcome. Sampling and Methods: We collected data from a total of 3,688 psychotherapeutic inpatients involved in psychodynamic group psychotherapy from 10 hospitals. Ipsatized SCL-90-R presymptom data were used as input variables for a series of cluster analyses combining hierarchical (Ward algorithm) and non-hierarchical (k-means) procedures. Results: The cluster analyses revealed a 7-cluster solution with the following subgroups: (1) insecure-paranoid, (2) neutralizing, (3) phobic-anxious, (4) aggressive, (5) insecure-phobic, (6) somatizing, and (7) obsessive-depressive. Cross-validation with independent data sets, as well as alternative statistical procedures, confirmed the stability of the 7-cluster solution. Correlations with clinical diagnoses and interpersonal problems indicate the clinical relevance of the cluster differentiation. The cluster insecure-phobic proved to be less beneficial when used as a predictor of treatment outcome. Furthermore, we found moderator effects between cluster assignment and pretreatment interpersonal problems: the overall amount of interpersonal problems seemed to be detrimental to the patients from the clusters insecure-phobic and somatizing, whereas a relatively (ipsatized) heightened level of dominance was advantageous for improving psychopathological complaints of the patients from the cluster aggressive. Conclusions: We could identify typical and clinically meaningful symptom clusters for the population of inpatients undergoing psychodynamic group psychotherapy in Germany. This finding could help strengthen clinical research which is led by the assumption that it is relevant to characterize patients by a specific pattern of psychopathological symptoms rather than or in addition to one (or more) distinct diagnostic categories.

Dismissing Attachment Characteristics Dynamically Modulate Brain Networks Subserving Social Aversion

Attachment patterns influence actions, thoughts and feeling through a person’s “inner working model”. Speech charged with attachment-dependent content was proposed to modulate the activation of cognitive-emotional schemata in listeners. We performed a 7 Tesla rest-task-rest functional magnetic resonance imaging (fMRI)-experiment, presenting auditory narratives prototypical of dismissing attachment representations to investigate their effect on 23 healthy males. We then examined effects of participants’ attachment style and childhood trauma on brain state changes using seed-based functional connectivity (FC) analyses, and finally tested whether subjective differences in responsivity to narratives could be predicted by baseline network states. In comparison to a baseline state, we observed increased FC in a previously described “social aversion network” including dorsal anterior cingulated cortex (dACC) and left anterior middle temporal gyrus (aMTG) specifically after exposure to insecure-dismissing attachment narratives. Increased dACC-seeded FC within the social aversion network was positively related to the participants’ avoidant attachment style and presence of a history of childhood trauma. Anxious attachment style on the other hand was positively correlated with FC between the dACC and a region outside of the “social aversion network”, namely the dorsolateral prefrontal cortex, which suggests decreased network segregation as a function of anxious attachment. Finally, the extent of subjective experience of friendliness towards the dismissing narrative was predicted by low baseline FC-values between hippocampus and inferior parietal lobule (IPL). Taken together, our study demonstrates an activation of networks related to social aversion in terms of increased connectivity after listening to insecure-dismissing attachment narratives. A causal interrelation of brain state changes and subsequent changes in social reactivity was further supported by our observation of direct prediction of neuronal responses by individual attachment and trauma characteristics and reversely prediction of subjective experience by intrinsic functional connections. We consider these findings of activation of within-network and between-network connectivity modulated by inter-individual differences as substantial for the understanding of interpersonal processes, particularly in clinical settings.

Outpatient Psychotherapy Reduces Health-Care Costs: A Study of 22,294 Insurants over 5 Years.

Background The project “Quality Assurance in Ambulatory Psychotherapy in Bavaria” (QS-PSY-BAY) focuses on the quality assurance of outpatient psychotherapy (OPT) in Germany in terms of symptom reduction and cost reduction under naturalistic conditions. In this study, we examined the effectiveness of psychotherapy in terms of pre–post cost reduction. Method The health-care costs of N = 22,294 insurants over a 5-year period were examined in a naturalistic longitudinal design. Six participating health insurance funds provided data on costs related to inpatient treatment, outpatient treatment, drugs, and hospitalization and work disability days. Results We found that the average annual total costs for inpatient and outpatient treatments as well as drug costs and work disability days increased from the second to the first year before OPT. Besides a large and significant reduction of work disability days (41.8%), hospitalization days (27.4%), and inpatient costs (21.5%) from the first year before versus the first year following OPT, we found evidence for long-term effects: the number of work disability days in the second year after OPT was lower (23.8%), and drug costs were higher than in the second year before OPT (41.5%). Conclusion We conclude that OPT as a part of the health insurance system is an investment which can pay off in the future especially in terms of lower inpatient costs and work disability.

Motivational determinants of interpersonal distress: How interpersonal goals are related to interpersonal problems

Abstract This study aimed to link interpersonal goals with interpersonal problems and psychological distress and to investigate changes in these variables during an inpatient psychotherapeutic treatment. Two hundred and fifty-eight patients treated in a psychosomatic hospital completed the German versions of the Circumplex Scales of Interpersonal Values, the Inventory of Interpersonal Problems, and the Outcome Questionnaire before and at the end of their treatment. Patients initially reported a strong need for bonding in the CSIV. Especially interpersonal goals related to avoidant, submissive, and altruistic behavior were associated with a wide range of different interpersonal problems, and were associated with more psychological distress. At the end of treatment, patients showed no substantial changes in their predominant communal goals, but significantly reduced submissive goals. Additionally, changes of these goals were associated with changes of various interpersonal problems and psychological distress. Focusing the value patients place on submissive experiences could help to improve interpersonal problems.

Partner-related attachment as a moderator of outcome in patients with social anxiety disorder—a comparison between short-term cognitive–behavioral and psychodynamic therapy.

This study investigated whether partner-related attachment characteristics differentially predict premature treatment termination as well as posttreatment and 1-year follow-up outcome in patients with social anxiety disorder treated with a manualized cognitive–behavioral therapy (CBT) or short-term psychodynamic therapy (PDT) in the SOPHO-NET (Social Phobia Psychotherapy Network) trial. Participants were 412 patients with social anxiety disorder (57% female) with a mean age of 35.4 years (SD = 12.1) who were randomized to either CBT or PDT. Partner-related attachment characteristics were measured using the revised Experiences in Close Relationships Questionnaire (ECR-R) at pretreatment. The Liebowitz Social Anxiety Scale was administered at pretreatment, posttreatment, and a 1-year follow-up. To address our research questions, linear regression models were applied. Furthermore, we compared CBT versus PDT patients within ECR-R quartiles. Treatment dropout did not differ between CBT and PDT and was not predicted by pretreatment attachment. In both treatment conditions, there was a trend for higher attachment anxiety to be associated with a more limited reduction in symptoms if controlling for pretreatment Liebowitz Social Anxiety Scale scores. Exploratory analyses showed that patients assigned to the highest quartile of the ECR-R-Avoidance distribution showed more benefit within the CBT condition posttreatment and at follow-up than the PDT condition. Our findings suggest that it may be useful to assess attachment characteristics in patients with social anxiety disorder before psychotherapeutic treatment. Patients characterized by very high pretreatment attachment avoidance (ECR-R-Avoidance >3.87) may specifically benefit more from CBT than from PDT. However, replication studies are needed that also should investigate nonlinear effects of pretreatment attachment.

Changes of attachment characteristics during psychotherapy of patients with social anxiety disorder: Results from the SOPHO-Net trial

Objectives Within a randomized controlled trial contrasting the outcome of manualized cognitive-behavioral (CBT) and short term psychodynamic therapy (PDT) compared to a waiting list condition (the SOPHO-Net trial), we set out to test whether self-reported attachment characteristics change during the treatments and if these changes differ between treatments. Research design and methods 495 patients from the SOPHO-Net trial (54.5% female, mean age 35.2 years) who were randomized to either CBT, PDT or waiting list (WL) completed the partner-related revised Experiences in Close Relationships Questionnaire (ECR-R) before and after treatment and at 6 and 12 months follow-up. The Liebowitz Social Anxiety Scale (LSAS) was administered at pre-treatment, post-treatment, and at 6-month and 1-year follow-up. ECR-R scores were first compared to a representative healthy sample (n = 2508) in order to demonstrate that the clinical sample differed significantly from the non-clinical sample with respect to attachment anxiety and avoidance. Results LSAS scores correlated significantly with both ECR-R subscales. Post-therapy, patients treated with CBT revealed significant changes in attachment anxiety and avoidance whereas patients treated with PDT showed no significant changes. Changes between post-treatment and the two follow-ups were significant in both conditions, with minimal (insignificant) differences between treatments at the 12- month follow-up. Conclusions The current study supports recent reviews of mostly naturalistic studies indicating changes in attachment as a result of psychotherapy. Although there were differences between conditions at the end of treatment, these largely disappeared during the follow-up period which is line with the other results of the SOPHO-NET trial. Trial registration Controlled-trials.com ISRCTN53517394