Jean-Nicolas Despland

A study of stability and change in defense mechanisms during a brief psychodynamic investigation.

This study investigated the stability of defensive functioning over the course of a 4-session Brief Psychodynamic Investigation (BPI). The sample included 61 outpatients from the Adult Psychiatry Department of the University of Lausanne, Switzerland. Defenses were measured from session transcripts using the DMRS quantitative method. Specific changes in defenses were found over the course of the ultrabrief investigation. First, the overall defensive functioning (ODF) score and the proportion of obsessional level defenses increased significantly, with a significant increase in intellectualization. Second, the number of defenses used and the proportion of narcissistic level defenses decreased, with a decreasing prevalence of devaluation and idealization. Third, high adaptive (mature) level defenses increased then decreased over the course of BPI, returning to their level at intake by the 4th session. Relief from distress and attending to the tasks of BPI tends to improve defensive functioning, but more likely returns it to usual levels rather than producing permanent change. Future studies will need to use designs that allow estimation of state changes while taking sufficient measurements to estimate potential changes in trait levels of defenses.

Patient's and Therapist's Views of Early Alliance Building in Dynamic Psychotherapy: Patterns and Relation to Outcome.

Patients and therapists have somewhat divergent perspectives of alliance. Usually in psychotherapy research, the focus is on the patients view of alliance, predicting parts of outcome. This study questions this hypothesis by applying the shape-of-change procedure to patients and therapists view of alliance-building processes in dynamic psychotherapy. The results of this naturalistic study indicate that none of the 3 patient patterns is related to outcome at the end of psychotherapy, but a specific therapists pattern--out of 2--is linked to positive symptom change. These results are discussed in the context of present research on therapeutic alliance, especially in terms of level and process, its measurement, and potential in predicting outcome in dynamic psychotherapy. (PsycINFO Database Record (c) 2008 APA, all rights reserved)

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.

Effects of Motive-Oriented Therapeutic Relationship in a Ten-Session General Psychiatric Treatment of Borderline Personality Disorder: A Randomized Controlled Trial

Background: Motive-oriented therapeutic relationship (MOTR) was postulated to be a particularly helpful therapeutic ingredient in the early treatment phase of patients with personality disorders, in particular with borderline personality disorder (BPD). The present randomized controlled study using an add-on design is the first study to test this assumption in a 10-session general psychiatric treatment with patients presenting with BPD on symptom reduction and therapeutic alliance. Methods: A total of 85 patients were randomized. They were either allocated to a manual-based short variant of the general psychiatric management (GPM) treatment (in 10 sessions) or to the same treatment where MOTR was deliberately added to the treatment. Treatment attrition and integrity analyses yielded satisfactory results. Results: The results of the intent-to-treat analyses suggested a global efficacy of MOTR, in the sense of an additional reduction of general problems, i.e. symptoms, interpersonal and social problems (F1, 73 = 7.25, p < 0.05). However, they also showed that MOTR did not yield an additional reduction of specific borderline symptoms. It was also shown that a stronger therapeutic alliance, as assessed by the therapist, developed in MOTR treatments compared to GPM (Z55 = 0.99, p < 0.04). Conclusions: These results suggest that adding MOTR to psychiatric and psychotherapeutic treatments of BPD is promising. Moreover, the findings shed additional light on the perspective of shortening treatments for patients presenting with BPD.

Change in defense mechanisms and coping over the course of short-term dynamic psychotherapy for adjustment disorder.

Short-term dynamic psychotherapy (STDP) has rarely been investigated with regard to its underlying mechanisms of change, even if psychoanalytic theory informs us about several potential putative mechanisms of change in patients. Change in overall defensive functioning is one. In this study, we explored the role of overall defensive functioning, by comparing it on the process level with the neighbouring concept of overall coping functioning. A total of N=32 patients, mainly presenting adjustment disorder, were included in the study. The patients underwent STDP up to 40 sessions; three sessions per psychotherapy were transcribed and analyzed by using two observer-rating scales: Defense Mechanism Rating Scales (Perry, 1990) and Coping Action Patterns (Perry, Drapeau, Dunkley, & Blake, 2005). Hierarchical linear modeling was applied to model the change over the course of therapy and relate it to outcome. Results suggest that STDP has an effect on the target variable of overall defensive functioning, which was absent for overall coping functioning. Links with outcome confirm the importance of the effect. These results are discussed from methodological and clinical viewpoints.

Alliance patterns over the course of short-term dynamic psychotherapy: The shape of productive relationships

Abstract The shape of alliance processes over the course of psychotherapy has already been studied in several process–outcome studies on very brief psychotherapy. The present study applies the shape-of-change methodology to short-term dynamic psychotherapies and complements this method with hierarchical linear modeling. A total of 50 psychotherapies of up to 40 sessions were included. Alliance was measured at the end of each session. The results indicate that a linear progression model is most adequate. Three main patterns were found: stable, linear, and quadratic growth. The linear growth pattern, along with the slope parameter, was related to treatment outcome. This study sheds additional light on alliance process research, underscores the importance of linear alliance progression for outcome, and also fosters a better understanding of its limitations.

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 CST.

The role of alliance in the relationship between therapist competence and outcome in brief psychodynamic psychotherapy.

Therapist competence is a key variable for psychotherapy research. Empirically, the relationship between competence and therapeutic outcome has shown contradictory results and needs to be clarified, especially with regard to possible variables influencing this relationship. A total of 78 outpatients were treated by 15 therapists in a very brief 4-session format, based on psychoanalytic theory. Data were analyzed by means of a nested design using hierarchical linear modeling. No direct link between therapist competence and outcome has been found, however, results corroborated the importance of alliance patterns as moderator in the relationship between therapist competence and outcome. Only in dyads with alliance change over the course of treatment was it clear that competence is positively related to outcome. These findings are discussed with regard to the importance for outcome of therapist competence and alliance construction processes.

Working alliance in communication skills training for oncology clinicians: A controlled trial

OBJECTIVE The aim of this study was to evaluate the impact of communication skills training (CST) on working alliance and to identify specific communicational elements related to working alliance. METHODS Pre- and post-training simulated patient interviews (6-month interval) of oncology physicians and nurses (N=56) who benefited from CST were compared to two simulated patient interviews with a 6-month interval of oncology physicians and nurses (N=57) who did not benefit from CST. The patient-clinician interaction was analyzed by means of the Roter Interaction Analysis System (RIAS). Alliance was measured by the Working Alliance Inventory - Short Revised Form. RESULTS While working alliance did not improve with CST, generalized linear mixed effect models demonstrated that the quality of verbal communication was related to alliance. Positive talk and psychosocial counseling fostered alliance whereas negative talk, biomedical information and patients questions diminished alliance. CONCLUSION Patient-clinician alliance is related to specific verbal communication behaviors. PRACTICE IMPLICATIONS Working alliance is a key element of patient-physician communication which deserves further investigation as a new marker and efficacy criterion of CST outcome.

Communication Skills Training in Oncology: It Works!

While the previous chapter by L. Fallowfield and V. Jenkins focuses on different communication skills training (CST) concepts currently being utilized, this chapter reviews and comments the scientific evidence of the impact of CST on improving communication skills. The aim of this chapter is not to provide a complete review of the evidence-this has already been done in systematic reviews-but to discuss the scientific evidence and reflect on the available results and relevant topics for further investigations.