Psychoanalytic Therapy

We commend Malhi et al. (1) and this journal for publishing excellent clinical practice recommendations for depression. We write to highlight new findings supporting Short-Term Psychodynamic Psychotherapy (STPP) for depression which, using the authorsÕ criteria requiring a systematic review of randomized controlled trials (1), may result in increasing the level of evidence for this treatment.

The neural circuits activated in a person carrying out actions, expressing emotions, and experiencing sensations are activated also, automatically via a mirror neuron system, in the observer of those actions, emotions, and sensations. It is proposed that this finding of shared activation suggests a functional mechanism of "embodied simulation" that consists of the automatic, unconscious, and noninferential simulation in the observer of actions, emotions, and sensations carried out and experienced by the observed. It is proposed also that the shared neural activation pattern and the accompanying embodied simulation constitute a fundamental biological basis for understanding another's mind. The implications of this perspective for psychoanalysis are discussed, particularly regarding unconscious communication, projective identification, attunement, empathy, autism, therapeutic action, and transference-countertransference interactions.

Objective: Change in three types of thought disorder as measured by Rorschach responses (contaminations, confabulations, and fabulized combinations) were assessed during intensive, longterm, psychodynamically oriented inpatient treatment. Method: Rorschach protocols for 90 seriously disturbed, treatment-resistant patients, 42 of whom were primarily preoccupied with primitive issues of interpersonal relatedness and used avoidant defenses (anaclitic patients) and 48 primarily preoccupied with primitive issues of self-definition and self-worth and used counteractive defenses (introjective patients), were evaluated at the beginning of treatment and, on average, 15 months into treatment.

The present study explored the effects on therapeutic outcomes of training therapists in brief manualized therapy. As part of the Vanderbilt II project, each of 16 therapists (8 psychiatrists and 8 clinical psychologists) treated 2 moderately disturbed adult patients using his or her customary short-term treatment methods; they then received a year of training in a manualized form of brief dynamic therapy, Time-Limited Dynamic Psychotherapy (TLDP); finally, they administered TLDP to 2 additional patients. It was hypothesized that training would result in improved outcomes generally and that differentially greater improvement would be seen in patients commonly considered less suitable for brief dynamic therapy. Outcome data obtained at termination failed to support either hypothesis. Measurements of interpersonal dependency obtained at a one-year follow-up were consistent with the first hypothesis, but the follow-up data were inconsistent with the second. A systematic review of the 32 posttraining cases suggested that the majority of the therapists had not achieved basic competence at TLDP.

The Working Alliance Inventory-Short Revised (WAI-SR) is a recently refi ned measure of the therapeutic alliance that assesses three key aspects of the therapeutic alliance: (a) agreement on the tasks of therapy, (b) agreement on the goals of therapy and (c) development of an affective bond. The WAI-SR demonstrated good psychometric properties in an initial validation in psychotherapy outpatients in the USA. The generalizability of these fi ndings is limited because in some countries a substantial portion of individual psychotherapy is delivered in inpatient settings. This study investigated and compared the psychometric properties of the WAI-SR in German outpatients (N = 88) and inpatients (N = 243). In both samples reliability (α > 0.80) and convergent validity with the Helping Alliance Questionnaire were good (r > 0.64). Confi rmatory factor analysis showed acceptable to good model fi t for the proposed Bond-Task-Goal model in both samples. Multi-group analysis demonstrated that the same constructs were measured across settings. Alliance ratings of outpatients and inpatients differed regarding the overlap of alliance components and the magnitude of the alliance ratings: The differentiation of the alliance components was poorer in inpatients and they reported lower alliances. Unique aspects of the alliance in inpatient treatment are discussed and a need for further research on the alliance in inpatient settings is pointed out. Overall, the WAI-SR can be recommended for alliance assessment in both settings.

This study examines whether alexithymia relates to specific interpersonal problems, based on data collected in a sample of mental health outpatients (N ϭ 404) and a student sample (N ϭ 157). Linear regression analysis, in which the effects of group, gender, and age were controlled, indicated that two interpersonal problems were significantly and reliably related to alexithymia: cold/distant and nonassertive social functioning. The theoretical relevance of the results for attachment and psychoanalytic theory is indicated, as well as implications of the findings for clinical practice.

The authors compared the effectiveness of 4 months (18 sessions) of cognitive-behavioral and supportive-expressive therapy for bulimia. Sixty patients obtained from clinical referrals to an eating disorders program who met modified DSM-III-R criteria for bulimia nervosa were randomly assigned to the two conditions. Treatments were delivered in an individual format, on an outpatient basis, by experienced therapists using treatment manuals. The primary outcome measures were self-induced vomiting, binge eating, and attitudes toward body weight and shape, which were assessed by self-report and structured interview. Fifty patients completed treatment, 25 in each condition. Both treatments led to significant improvements in specific eating disorder symptoms and in psychosocial disturbances. Supportive-expressive therapy was just as effective as cognitive-behavioral therapy in reducing binge eating. Where treatment differences were found, they favored cognitive-behavioral therapy. Cognitiv...

Background. Insufficient evidence exists for a viable choice between long-and short-term psychotherapies in the treatment of psychiatric disorders. The present trial compares the effectiveness of one long-term therapy and two shortterm therapies in the treatment of mood and anxiety disorders.

PURPOSE General practitioners (GPs) occupy a central position in health care and often have demanding working situations. This corps shows signs of exhaustion, and many consider quitting their job or plan to retire early. It is therefore urgent to fi nd ways of improving GP's satisfaction with their work. One approach might be Balint group participation. The aim of this study was to explore GPs' experience of participating in Balint groups and its infl uence on their work life. METHODS We conducted a descriptive, qualitative study. Nine GPs who had participated in Balint groups for 3 to 15 years were interviewed. A phenomenologic analysis was carried out to describe the phenomenon of Balint group participation. RESULTS The GPs perceived that their Balint group participation infl uenced their work life. Analyses revealed several interrelating themes: competence, professional identity, and a sense of security, which increased through parallel processes, creating a base of endurance and satisfaction, thus enabling the GPs to rediscover the joy of being a physician. CONCLUSIONS The GPs in this study described their Balint group participation as benefi cial and essential to their work life as physicians in several ways. It seemed to increase their competence in patient encounters and enabled them to endure in their job and fi nd joy and challenge in their relationships with patients. Balint groups might thus help GPs handle a demanding work life and prevent burnout. These groups might not suit all GPs, however, and additional ways to reduce stress and increase job satisfaction should be offered.

The authors examined the relation between therapist process variables (adherence and competence) and subsequent symptomatic change in patients. Twenty-nine depressed patients were seen in 16 sessions of weekly supportive expressive (SE) dynamic psychotherapy. Change in depression from intake to Session 3 predicted higher ratings of adherence to expressive (interpretative) techniques during Session 3 but not their competent delivery. Partialling pretreatment psychiatric severity, therapists' adherence to use of expressive techniques, and previous symptomatic improvement, relatively competent delivery of SE-specific expressive techniques predicted subsequent improvement in depression. Secondary analyses addressing alternative explanations (such as the role of either therapeutic alliance or general therapeutic skills) did not change the results.

Objective: To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making. Method: A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives. Results: The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative. Conclusion: These up-to-date recommendations provide an evidencebased framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.

In the present review, we examine one of the critical issues that have been raised about evidence-based treatments and their portability to real-world clinical settings: namely, the presence of comorbidity in the participants who have been treated in these studies and whether the presence of comorbidity predicts or moderates treatment outcomes. In doing so, we examine treatment outcomes for the four most commonly occurring childhood psychiatric disorders: Anxiety disorders, affective disorders, attention deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD)/conduct disorder (CD). For each of these disorders, we first review briefly the prevalence of comorbidity in epidemiological and clinical samples and then highlight the evidence-based treatments for these disorders. We next determine the effects of comorbidity on treatment outcomes for these disorders. For the most part, comorbidity in the treated samples is the rule, not the exception. However, the majority of studies have not explored whether comorbidity predicts or moderates treatment outcomes. For the not insignificant number of studies that have examined this issue, comorbidity has not been found to affect treatment outcomes. Notable exceptions are highlighted and recommendations for future research are presented.

This article provides a contemporary view of the psychodynamics of borderline personality disorder~BPD! from a developmental psychopathology perspective. We first briefly describe the evolution of the borderline construct in psychoanalysis and psychiatry. Then we provide clinically and empirically informed model of domains of personality function and dysfunction that provides a roadmap for thinking about personality pathology from a developmental psychopathology standpoint and examine the nature and phenomenology of BPD in terms of these domains of functioning. Next, we describe prominent dynamic theories of etiology of BPD and examine these in relation to the available research. Finally, we describe psychodynamic conceptions of treatment and the way BPD phenomena manifest in treatment, followed again by consideration of relevant research, particularly on transference-countertransference constellations empirically identified in the treatment of patients with BPD.

Patients hospitalized for psychiatric reasons exhibit significantly elevated risk of suicide, yet the research literature contains very few outcome studies of interventions designed for suicidal inpatients. This pilot study examined the inpatient feasibility and effectiveness of The Collaborative Assessment and Management of Suicidality (CAMS), a structured evidence-based method for risk assessment and treatment planning . The study used an open-trial, case-focused design to assess an inpatient adaptation of CAMS, spread over a period averaging 51 days. The intervention was provided via individual therapy to a convenience sample of 20 patients (16 females and four males, average age 36.9) who were hospitalized with recent histories of suicidal ideation and behavior. Results showed statistically and clinically significant reductions in depression, hopelessness, suicide cognitions, and suicidal ideation, as well as improvement on factors considered "drivers" of suicidality. Treatment effect sizes were in the large range (Cohen's d Ͼ .80) across several outcome measures, including suicidal ideation. Although these findings must be considered preliminary due to the lack of a randomized control group, they merit attention from clinicians working with patients at risk for suicide. This study also supports the feasibility of implementing a structured, suicide-specific intervention for at-risk patients in inpatient settings.

Objective: To examine the efficacy and maintenance of developmentally adapted prolonged exposure therapy for adolescents (PE-A) compared with active control time-limited dynamic therapy (TLDP-A) for decreasing posttraumatic and depressive symptoms in adolescent victims of single-event traumas. Method: Thirty-eight adolescents (12 to 18 years old) were randomly assigned to receive PE-A or TLDP-A. Results: Both treatments resulted in decreased posttraumatic stress disorder and depression and increased functioning. PE-A exhibited a greater decrease of posttraumatic stress disorder and depression symptom severity and a greater increase in global functioning than did TDLP-A. After treatment, 68.4% of adolescents beginning treatment with PE-A and 36.8% of those beginning treatment with TLDP-A no longer met diagnostic criteria for posttraumatic stress disorder. Treatment gains were maintained at 6and 17-month follow-ups. Conclusions: Brief individual therapy is effective in decreasing posttraumatic distress and behavioral trauma-focused components enhance efficacy. J. Am.

The authors describe Fairbairn's view of the personality as a system of parts of self and object in dynamic relation, formed in the context of dependent early relationships and replayed in the intensely intimate and physical relationship of marriage. Through Klein's concept of projective identification, a spouse finds lost parts of the self in the partner, where they may flourish and be reintegrated into the self or they may be held hostage. Marriage is an opportunity for reworking the dynamic relation of parts of the self as they are modified through mutual unconscious interaction with the spouse, but it may become a closed system that inhibits growth of the individual partners. Object relations couple therapy aims to breach the closed system of the unhappy marriage, and offers an enlarged space for understanding that encourages the spouses to provide a better holding environment for each other. Not directive, didactic or symptom-focused, object relations therapy values aff...

This study compared the impact of helpful and hindering events, as perceived by 40 clients, in two forms of psychotherapy: an exploratory, relationship-oriented thetapy, and a ptescriptive, cognitive/behavioutal thetapy. All clients teceived eight sessions ofeach type oftreatment in a crossover design. Events were obtained by self-report both during and at the end of each period, and content analysed for type of therapeutic impact by three ttained taters. Results showed that during treatment the most commonly occurring helpful impacts across both types of treatments were'problem solution', 'awareness'and'reassurance', while the most commonly occurring hindering impact was 'unwanted thoughts'. Similar impacts were reported at the end of each period, with the addition of 'personal contact '. In addition, it was found that 'problem solution ' and ' reassutance ' impacts were more commonly reported in prescriptive treatment, whereas 'awareness' and 'personal contact'impacts were more prevalent in exploratory treatment. Only the ptevalence of 'unrvanted thoughts' was cortelated (negatively) with outcome. Some possible reasonb for the lack of correlation between reported impacts and outcome are suggested.

Recent research on infant development is reviewed to consider its implications for psychodynamic theory and practice. To address the question of the importance of early experiences for development, research on continuities and discontinuities in development, temperament, motivational systems in infancy, affect development and regulation, development of the sense of self, and infant-caregiver attachment are reviewed. Two major implications emerge, both emphasizing the need for more complexities in our conceptualizations. First, research on infant development underscores the importance of context in development and cautions about the limits of reductionistic thinking and theories. Second a major paradigmatic shift away from the fixation-regression model of psychopathology and development is indicated. A new model that better fits available data is proposed instead. In this continuous construction model, there is no need for regression, and ontogenetic origins of psychopathology are no longer necessarily tied to specific critical or sensitive periods in development. Implications for psychodynamic treatment are also described.

How can we study the 'quality of psychoanalytic treatments'? The authors attempt to answer this question by discussing a naturalistic, multi-perspective and representative follow-up study of psychoanalyses and long-term psychoanalytic psychotherapies. We studied a representative sample (n ¼ 401) of all the patients who had terminated their psychoanalytic treatments with members of the German Psychoanalytical Association (DPV) between 1990 and 1993. Between 70 and 80 per cent of the patients achieved (average 6.5 years after the end of treatment) good and stable psychic changes according to the evaluations of the patients themselves, their analysts, independent psychoanalytic and non-psychoanalytic experts, and questionnaires commonly applied in psychotherapy research. The evaluation of mental health costs showed a cost reduction through fewer days of sick leave during the seven years following the end of long-term psychoanalytic treatments. The results achieved using non-psychoanalytical instruments are complemented by the richness of the idiosyncratic findings, gained by the psychoanalytic research instruments.

Relational psychoanalysis has emphasized that the analyst's awareness of her failures in recognition and hurtful re-opening of old wounds requires of her an internal struggle with self-regulation, with her own shame and guilt. This struggle takes place in the watchful presence of someone who is (sometimes hypervigilantly) listening to and monitoring the signs of the analyst's internal state. If, in response to the patient's hyper-arousal, the analyst retreats from the 'music' of mutual regulation into a dissociative use of observation in order to calm down, the patient can feel it. If, however, we are mindful of our failures, gradually we will learn together to recover from ruptures in attunement, and thus become sensitive to and use more effectively the inexplicable gaps created by the patient's unintegrated or warring self-parts and the analyst's failure to contain them. Thus moments of excess that fail to evoke a mirroring knowledge can serve instead to signal the unformulated, undifferentiated malaise, despair or fear.

Background: Long-term forms of depression represent a significant mental health problem for which there is a lack of effective evidence-based treatment. This study aims to produce findings about the effectiveness of psychoanalytic psychotherapy in patients with treatment-resistant/treatment-refractory depression and to deepen the understanding of this complex form of depression.

The authors present preliminary psychodynamic findings from a naturalistic study of borderline personality disorder compared to antisocial personality disorder and bipolar type II (depression with hypomania) affective disorder. An independent psychodynamic interview of each subject was videotaped from which ratings were made of the presence of 22 defense mechanisms and 11 psychodynamic conflicts. A factor analysis of ratings from 81 subjects supported the separation of borderline (splitting, projective identification) from narcissistic defenses (devaluation, omnipotence, idealization, mood-incongruent denial). While certain groups of defenses were associated with each diagnosis, defense ratings did not significantly discriminate the three diagnostic groups, suggesting a limit to their diagnostic value. Among 27 subjects rated, borderline personality was strongly associated with two conflicts: separation-abandonment, and a global conflict over the experience and expression of emotional needs and anger. Antisocial personality was psychodynamically distinct and more heterogeneous. Bipolar type II was associated with two hypothesized depressive conflicts: dominant other and dominant goal. Chronic depression, which was more common in both personality disorder groups than in bipolar type II, was associated with a third depressive conflict, overall gratification inhibition. Overall, conflicts were powerful discriminators of the three diagnostic groups. The heuristic value of these findings is discussed. FOR THE PAST SEVERAL YEARS we have been conducting a study of the psychopathology and course of borderline personality disorder to determine whether this diagnosis is valid and can be discriminated from other disorders. We selected two near neighbor disorders for this comparison on which there has been systematic research. We chose antisocial personality disorder because of a possible overlap in impulse pathology, and bipolar type II affective disorder because recurrent depression and hypomania represent disturbances in affect regulation which may overlap with borderline personality disorder. To determine the discriminate validity of borderline personality disorder from these two comparison disorders, we have examined descriptive features, and the prevalence of accompanying syndromes such as depression, alcohol, and drug abuse. We are following their course for patterns of impulse problems, social role dysfunction, and response to life events (Perry 1985); (Perry and Cooper 1985). In addition to this descriptive work, we are systematically examining the psychodynamics of these disorders using a framework of defense mechanisms and psychodynamic conflicts, ascertained outside of psychoanalytic or other treatment contexts. This preliminary report addresses the question of whether the borderline personality disorder is associated with psychodynamics that differentiate it from these two comparison disorders. The psychodynamic literature has generally viewed the antisocial and borderline personality disorders as strongly related or even identical regarding their underlying psychodynamics. Kernberg (1975) stated that most cases of antisocial personality disorder have an underlying borderline personality organization. This concept is defined by the presence of intact reality testing, identity diffusion, and the use of certain primitive defenses revolving around splitting, which defend against the activation of pathological internalized object relations (Kernberg, 1981). Kernberg has suggested that the major deficit in borderline psychopathology is the inability to integrate positive and negative identifications and introjects. The reliance

A recent examination of the literature concerning countertransference and its developments reveals its clinical usefulness in different psychoanalytical cultures. Nevertheless, a shortage of publications is apparent with respect to its approach in supervision. The authors' aim in this study was to examine the concepts of transference and countertransference and how countertransference is approached in supervision, in the training of candidates, at an institute of psychoanalysis belonging to a society affi liated to the International Psychoanalytical Association (IPA). Qualitative research was carried out, interviewing supervisors and supervisees. Through analysis of the material acquired, the authors classifi ed the data into initial, intermediate and fi nal categories. The principal fi ndings were subdivided into three categories: the concepts of transference and countertransference, psychoanalytical listening and the complementarity of the phenomena, and the approach to countertransference. The concepts of transference and countertransference predominantly used by those interviewed are based on the totalistic outlook. Countertransference in supervision has been approached in a more direct and objective way when compared with the previous period, although great care is taken to delimit the boundaries between supervision and personal analysis. The main aim of supervision is to broaden comprehension and to deepen the interpretations directed towards the patient. These fi ndings suggest that the evolution of the concept of countertransference in different psychoanalytical cultures and developments in the analytical fi eld are contributing to this change.