J. Vyskocilova

P-1165 - Therapeutic letters - changing the emotional schemas using writing letters to significant caregivers

emotional schemas, therapeutic letters, emotional processing, cognitive behavioral therapy, therapeutic strategy, dissociation; anxiety disorders; depression, personality disorders Abstract The letter writing has been used as a strategy in different psychotherapeutic approaches. Therapeutic letters are intended to extend the work of therapy beyond the consulting room door by continuing the meaning-making that occurred in a therapeutic conversa- tion. Although CBT stresses the importance of cognitions or thoughts in activating or maintaining negative affects, there has been increasing emphasis on considering the role of emotional processing. Many of our patients believe that one should be rational and logical all the time, never have conflicting feelings, and should ruminate in order to figure things out. Meaningful cognitive and simultaneously experiential technique for working with deep emotional schemas, formatted in childhood, is writing therapeutic letters. Inclusions of emotion regulation skills in the treatment especially for patients with personality dis- order enhance the efficacy of CBT. We used therapeutic letters to help the patient identify difficult feelings, process them in a way that maybe they could not in a therapy session, and finally get release and freedom from them. Typical therapeutic letters are address to important close persons from the patient life, like parents, siblings, a partner and friends, children. The patient uses the letter to impress his/her feeling and needs, inclusive defenses of his rights in past and present. Patient writes a letter at home, and he brings it then into the session and reads it to the therapist. These letters are not intended to be sent to that important person, but to process strong emotions inside the patient. In fact the patient writes a letter to his inner representation of an important person, who was connected with the development of the maladaptive schemas. The letter-writing process is inherently collaborative and enables the patient to work at his or her own pace while also facilitating patient empowerment.

930 – Transference and countertransference in cognitive behavioral therapy

Both patients and psychotherapists can experience strong emotional reactions towards each other in what are termed transference and countertransference within therapy. In the first part of this review, we discuss transference issues. Although not usually part of the obvious language of cognitive behavioral therapy (CBT), examination of the cognition. Both the literature and our experience underscore the importance of careful and open examination of both transference and counter-transference issues in CBT and their necessary incorporation in the complete management of all patients undergoing CBT.s related to the therapist, is an integral part of CBT, especially in working with difficult patients. In the second part, we cover countertransference issues. We describe schematic issues that give rise to therapist counter-transference and explain how this interacts in different types of patient therapist encounter. We also examine ways in which the therapist can use CBT to help him/her modify the countertransference and, in the process, assist the patient. Our work studied the self-reflection about transference and counter-transference in 52 cognitive behavioral therapy students and practitians using both qvalitative reseach (structure interview) and quantitative approache (using questinnaire). Differences between students of CBT who start the training, before finish the traning and CBT supervisors are analyzed. This paper was supported by the research grants IGA MZ CR 10301-3/2009

1226 – Changing the emotional schemas using writing letters to significant caregivers

The letter writing is a psychoterapeutic strategy, which can help to the patients to cope with the relationship to the significant people from their childhood. Method The purpose of writing letters is to experience and to understand their own feelings, to cope with strong emotional experiences, which are related to the injuries in the childhood. We present specific examples of the letters from our patients in last 15 years of our experience, when this technique is mainly used in patients with personality disorders, affective and anxiety disorders in the therapy and also using internet. Results The result is a profound change in beliefs about themselves and others. The basic types of therapeutic letters are these four: not censured letter, emphatic letter from the “other side”, the letter to the “inner child” of the significant person and the letter “visit-card”. In not censured letter the patients primarily reflect the negative feelings that hurt them in childhood. The emphatic letter from the “other side” is the ideal answer the patients would have wanted to get away from the significant person; patients formulate the particular wishes and expectations, which meet in a fictional response (encouraging selfconfidence, assurance of love, respect). The “visit-card” letter is the censured letter in “adult to adult” mode, written with respect for oneself and significant person, directed towards reconciliation. Fonetický přepis Supported by IGA MZ CR NT 11047-4/2010.

P-141 - Influence of personality disorder on the treatment of panic disorder - comparison study

UNLABELLED Most clinicians tend to believe that the occurrence of the anxiety disorder in comorbidity with a personality disorder often leads to longer treatment, worsens the prognosis, and thus increasing treatment costs. The study is designed to compare the short-term effectiveness of combination of cognitive behavioral therapy and pharmacotherapy in patient suffering with panic disorder with and without personality disorder. METHOD We compare the efficacy of 6th week therapeutic program and 6th week follow up in patients suffering with panic disorder and/or agoraphobia and comorbid personality disorder (29 patients) and panic disorder and/or agoraphobia without comorbid personality disorder (31 patients). Diagnosis was done according to the ICD-10 research diagnostic criteria confirmed with MINI and support with psychological methods: IPDE, MCMI-III and TCI. Patients were treated with CBT and psychopharmacs. They were regularly assessed in week 0, 2, 4, 6 and 12 by an independent reviewer on the CGI (Clinical Global Improvement) for severity and change, PDSS (Panic Disorder Severity Scale), HAMA (Hamilton Anxiety Rating Scale), SDS (Sheehan Disability Scale), HDRS (Hamilton Depression Rating Scale), and in self-assessments BAI (Beck Anxiety Inventory) and BDI (Beck Depression Inventory). RESULTS A combination of CBT and pharmacotherapy proved to be the effective treatment of patients suffering with panic disorder and/or agoraphobia with or without comorbid personality disorder. The 12th week treatment efficacy in the patients with panic disorder without personality disorder had been showed significantly better compared with the group with panic disorder comorbid with personality disorder in CGI and specific inventory for panic disorder--PDSS. Also the scores in depression inventories HDRS and BDI showed significantly higher decrease during the treatment comparing with group without personality disorder. But the treatment effect between groups did not differ in objective anxiety scale HAMA, and subjective anxiety scale BAI.

Cognitive behavioral therapy in pharmacoresistant obsessive-compulsive disorder.

Background The aim of the study was to determine whether patients with obsessive–compulsive disorder (OCD) resistant to drug therapy may improve their condition using intensive, systematic cognitive behavioral therapy (CBT) lasting for 6 weeks, and whether it is possible to predict the therapeutic effect using demographic, clinical, and selected psychological characteristics at baseline. Methods Sixty-six OCD patients were included in the study, of which 57 completed the program. The diagnosis was confirmed using the structured Mini International Neuropsychiatric Interview. Patients were rated using the objective and subjective forms of the Yale–Brown Obsessive Compulsive Scale, objective and subjective forms of the Clinical Global Impression, Beck Anxiety Inventory, Beck Depression Inventory, Dissociative Experiences Scale, 20-item Somatoform Dissociation Questionnaire, and the Sheehan Disability Scale before their treatment, and with subjective Yale–Brown Obsessive Compulsive Scale, objective and subjective Clinical Global Impression, Beck Anxiety Inventory, and Beck Depression Inventory at the end of the treatment. Patients were treated with antidepressants and daily intensive group CBT for the 6-week period. Results During the 6-week intensive CBT program in combination with pharmacotherapy, there was a significant improvement in patients suffering from OCD resistant to drug treatment. There were statistically significantly decrease in the scores assessing the severity of OCD symptoms, anxiety, and depressive feelings. A lower treatment effect was achieved specifically in patients who 1) showed fewer OCD themes in symptomatology, 2) showed a higher level of somatoform dissociation, 3) had poor insight, and 4) had a higher initial level of overall severity of the disorder. Remission of the disorder was more likely in patients who had 1) good insight, 2) a lower initial level of anxiety, and 3) no comorbid depressive disorder.

Transference in Cognitive Behavioral Therapy and Its Ethical Implications

Transference is part ofalmost all human relations, and therefore is also a part of any therapeuticrelationship. Classic CBT literature deals with transference only marginally. Butto the work with complex patients, the conceptualization of transference andcounter- transference need to be developed, as well as dealing with ethicalissues that relate to the transference. Method Articles and studies were identified throughPubMed, Web of Science and Scopus databases as well as existing reviews. Thesearch terms included “transference”, “cognitivebehavioral therapy”, “acceptance and commitment therapy”,“schema therapy,” “dialectic behavioral therapy” Compassiontherapy“, ”ethics “in different combinations. Other relevanttexts were searched by references found articles. Outcome Transference relationship can work inconjunction with therapy and helps to achieve its objectives, or restricts thetherapy, distorts it or blocks. For uncomplicated psychiatric disorders and tosolve simple problems CBT doesn´t address the therapeutic relationship. Conversely, therapeutic relationship becomes the focus of the therapy in clientswith personality disorders. It can be used to identifying automatic thoughts, dysfunctional assumptions and core beliefs well as to their changing. Transferencemay also be misconduct in favor the therapist at the expense of the client. Thecrossing of the borders can be done unconsciously or consciously. Ethicalreflection of the therapeutic relationship is possible only when the therapistconceptualizes recognized transference of the client and also owncounter-transference reactions. Self-reflection, however, must be supplementedby asking the relevant ethical questions.

Group CBT for Patients with Obsessive Compulsive Disorder – Predictors of Therapeutic Efficacy

OBJECTIVE: The aim of our study was to establish the efficacyof CBT on the sample of non-selected medication-resistant patients with OCDand to search for predictors of therapeutic response in such a group. Methods The treatment was carried out under usual conditionsat the department for anxiety disorders. Systematic CBT steps were tailored tothe needs of each patient. Pharmacology treatment remained grosslyunchanged during the trial period. We used the following outcome measures in thestudy: Yale-Brown Obsessive Compulsive Scale, subjective version (S-Y-BOCS),the Clinical Global Impression – Severity of Illness scale (CGI-S), BeckDepression Inventory (BDI), Beck Anxiety Inventory (BAI), Somatoform DissociationQuestionnaire (SDQ-20) and Dissociative Experience Scale (DES). The primary outcomemeasure was a decrease by 35% in Y-BOCS rating. Remission was defined as a12 point score or lower in Y-BOCS and 1 or 2 points in CGI-S. Results 47 patients completed the study (19 male and 28female). One female patient refused to participate. All patients completed atleast 5 weeks of intensive CBT programme and showed significant improvement on Y-BOCS, CGI-S, and BDI scales. At the end of the treatment 40.4% of the patientsachieved clinical remission according to the CGI-S scale. The maincharacteristics present at the beginning of the trial increasing probability of achievingimprovement or remission during the treatment were a Y-BOCS score lower than 22, goodinsight, higher resistance to symptoms, low level of dissociation, andaggressive obsessions. ¨ Conclusion As negative predictors we identified higherscores in Y-BOCS, poorer insight, low resistance to symptoms, high level ofdissociation, obsessions focused on control/symmetry and obsessiveslowness/ambivalence as associated with poor improvement. Supported by grant IGA MZ CR NT 11047-4/2010

Emotional Processing Using Role Playing and Therapeutic Letters in the Treatment of Personality Disorders

Meaningful cognitive and simultaneously experiential technique for working with deepemotional schemas, formatted in childhood, is writing therapeutic letters. Inclusions of emotion regulation skills in the treatment especially forpatients with personality disorder enhance the efficacy of CBT. Therapeuticletters are intended to extend the work of therapy beyond the consultingroom door by continuing the meaning-making that occurred in a therapeuticconversation. We usedtherapeutic letters to help the patient identify difficult feelings, processthem in a way that maybe they could not in a therapy session, and finally getrelease and freedom from them. Typicaltherapeutic letters are address to important close persons from thepatient life, like parents, siblings, a partner and friends, children. Thepatient uses the letter to impress his/her feeling and needs, inclusivedefenses of his rights in past and present. Patientwrites a letter at home, and he brings it then into the session and reads it tothe therapist. These letters are not intended to be sent to thatimportant person, but to process strong emotions inside the patient. In fact thepatient writes a letter to his inner representation of an important person ,who was connected with the development of the maladaptive schemas. Theletter-writing process is inherently collaborative and enables the patient towork at his or her own pace while also facilitating patient empowerment.

Emotional Processing of Traumatic Emotions and Early Experiences Using the Therapeutic Letters, Role Playing and Imagination in Borderline and Other Difficult Patients

In many patients cognitivereconstruction helps to understand their problems in life and symptoms of stressor psychiatric disorders. Change in the thoughts and beliefs help them to feelbetter. But there are many patients who suffer with strong traumaticexperiences deep in their mind and typically dissociate them or want to avoidthem voluntarily. There is typical for patients suffering with dissociativedisorders, borderline personality disorder and many people with variouspsychiatric disorders who were abused in childhood. The processing of thetraumatic emotions from childhood can be helpful in the treatment of thesepatients. For the help is important: a) Understanding what washappen in childhood b) Making clear of repeatedfigures of maladaptive behaviors, mostly in interpersonal relations b) Making a connectionbetween childhood experiences and here and now emotional reactions on varioustriggers c) Experiencing repeatedlythe traumatic memories and elaborate them with imaginal coping. We describe: - how to map and elaborate emotional schemas - Socratic questioning with the patients with traumatic memories - how to work with traumatic experiences from childhood in borderlinepersonality disorder.

Transference and Countertransference in CBT and Schematherapy of Personality Disorders

Countertransference occurs in CBT when the relationship with the patientactivates automatic thoughts and schemas in the clinician, and these cognitionshave the potential for influencing the therapy process. Countertransferencealso occurs during supervision and is an indispensable part of the supervisors response to the supervisee. CBT is typically short-termtreatment – intensity of transference is usually muchlower than in longer-term, dynamically oriented psychotherapy. Neverthelessduring the long-term CBT of the personality disorder or other complex cases, high intensity of transference and countertransference can develop. Schema therapy shares the view thatschemas are crucial to understanding of personality disorders, but also canhelp to understand the emotional reaction of therapist. A mode is the set ofschema operations that are in one moment functioning for a person. It is acircumscribed complex pattern of emotional, cognitive a behavioral experiences, which operate in typical situations. When therapist suspects that countertransferencemay be developing, he/she could try to identify her/his automatic thoughts andschemas. More comprehensive approach is to quickly identify in which modehim/her are at that moment and reflect it such reaction is for the patientbenefit or not. Understanding therapist countertransference reactions andtheirs management are a significant point of supervision. Self-reflection and realizing the countertransference can therapist help toovercome it and may be necessary for overcoming stagnation in therapy. Understanding own mode and theirflipping into the therapeutic session is an important tool in psychotherapy andsupervision.