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A Secure Base Clinical Applications Of Attachment Theory

Context The place of long-term psychodynamic psychotherapy (LTPP) within psychiatry is controversial. Convincing outcome research for LTPP has been lacking. Objective To examine the effects of LTPP, especially in complex mental disorders, ie, patients with personality disorders, chronic mental disorders, multiple mental disorders, and complex depressive and anxiety disorders (ie, associated with chronic course and/or multiple mental disorders), by performing a meta-analysis. Data Sources Studies of LTPP published between January 1, 1960, and May 31, 2008, were identified by a computerized search using MEDLINE, PsyclNFO, and Current Contents, supplemented by contact with experts in the field. Study Selection Only studies that used individual psychodynamic psychotherapy lasting for at least a year, or 50 sessions; had a prospective design; and reported reliable outcome measures were included. Randomized controlled trials (RCTs) and observational studies were considered. Twenty-three studies involving a total of 1053 patients were included (11 RCTs and 12 observational studies). Data Extraction Information on study characteristics and treatment outcome was extracted by 2 independent raters. Effect sizes were calculated for overall effectiveness, target problems, general psychiatric symptoms, personality functioning, and social functioning. To examine the stability of outcome, effect sizes were calculated separately for end-of-therapy and follow-up assessment. Results According to comparative analyses of controlled trials, LTPP showed significantly higher outcomes in overall effectiveness, target problems, and personality functioning than shorter forms of psychotherapy. With regard to overall effectiveness, a between-group effect size of1.8 (95% confidence interval [Cl], 0.7-3.4) indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96% of the patients in the comparison groups (P= .002). According to subgroup analyses, LTPP yielded significant, large, and stable within-group effect sizes across various and particularly complex mental disorders (range, 0.78-1.98). Conclusions There is evidence that LTPP is an effective treatment for complex mental disorders. Further research should address the outcome of LTPP in specific mental disorders and should include cost-effectiveness analyses.

Effectiveness of Long-term Psychodynamic Psychotherapy : A Meta-analysis. Commentary

Maps of Narrative Practice

The therapeutic value of alliance is a contested supposition. Although many theorists and researchers believe that alliance is therapeutic in itself, others see it as a byproduct of effective treatment or as a common nonspecific factor enabling the truly effective ingredients of treatment to work. For many years, the debate was confined mainly to the domain of theory, and no studies were available to confirm which of these approaches is correct. The only empirical evidence that existed was studies showing a correlation between alliance and outcome, and advocates of the above conflicting opinions used the same correlation to prove the validity of their position. Over the last few years, however, a revolution has taken place in alliance research, which brings this theoretical debate into the realm of the empirical. Several recent alliance studies have applied advanced methodologies to achieve this aim. Based on an integration of these studies, the present article proposes a new model for understanding the potential therapeutic role of alliance as sufficient to induce change by itself. The model stresses the importance of differentiating between patients' general tendencies to form satisfying relationships with others, which affect also the relationship with the therapist ("trait-like" component of alliance), and the process of the development of changes in such tendencies through interaction with the therapist ("state-like" component of alliance). The former enables treatment to be effective; the latter makes alliance therapeutic. Based on the literature, this article attempts to determine which of these components is the predictor of treatment outcome. (PsycINFO Database Record

Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances.

General view on the criteria utilized for psychiatric diagnoses feighner research diagnostic criteria diagnostic and statistical manual of mental disorders dsm iii

In the absence of one intervention that can cure all patients with major depressive disorder (MDD), the leading cause of disability worldwide, increased attention has been focused on selecting the best treatment based on patient characteristics. Theory-driven hypotheses for selecting the best treatments have not yet been adequately investigated. The present study tested the a priory hypothesis that attachment orientations may determine whether patients benefit more from a treatment where alliance provides a facilitative environment for the treatment to work, as in the case of supportive-expressive psychotherapy, vs. where alliance is conceptualized as an active ingredient in itself, as in the case of supportive psychotherapy. To test the hypothesis that attachment orientation moderates the effect of treatment condition on outcome, we conduct a randomized controlled trial (RCT). One hundred patients are randomized to 16 sessions of either supportive-expressive or supportive psychotherapy for MDD, conducted by experienced psychologists. The primary outcome is change in the Hamilton Rating Scale for Depression. Secondary outcome measures include self-reported depressive and other symptoms, psychological and interpersonal functioning, quality of life, and the presence of the diagnosis of depression. Additional measures include hormonal levels, motion synchrony, and acoustic attributes, performance on cognitive tasks, and narrative material (collected from the sessions and from interviews). The RCT will expand our understanding of how the outcome of treatment can be optimized by identifying the most promising role of alliance in treatment, based on patients’ pre-treatment attachment orientation. Results will contribute to the ongoing theoretical debate concerning the differential efficacy of various psychotherapeutic approaches for patients with different attachment orientations. The RCT will also contribute to progress toward personalized treatment by informing therapists about which of two approaches are most effective with patients based on their attachment styles. Clinicaltrials.gov Identifier: NCT02728557
 submitted on the 15.3.16. Funding: The Israel Science Foundation. Trial status: Recruitment is ongoing.

/pdf/identifying-the-most-suitable-treatment-for-depression-based-3k85ylqxa4.pdf

Identifying the most suitable treatment for depression based on patients’ attachment: study protocol for a randomized controlled trial of supportive-expressive vs. supportive treatments

Tourism and depressive symptoms

Approximately one in five patients drops out of treatment before its completion. Little is known about consistent predictors of dropout, and most studies focus on patients’ demographic characteristics. A mass of information is collected daily at intake in clinical practice. Based on psychodynamic theoretical conceptualizations and accumulative clinical experience, this information may help predict dropout, and thereby expand the empirically based predictors of dropout. Objective: The present study aims at bridging between scientific research and clinical practice by investigating potential predictors of unilateral termination collected at intake, before therapy, in addition to predictors already identified in the literature. Method: The study was based on data from 413 patients from a university consulting center. Each patient completed a pre-intake questionnaire collecting demographic information, and underwent an interview conducted by a professional intaker. Results: Results indicate that the c...

Patient demographics and psychological functioning as predictors of unilateral termination of psychodynamic therapy.

drinking (other than water) for 30 min before arrival, and to rinse their mouth 10 min before saliva collection. They were also asked to refrain from romantic or intimate touch for 30 min before arrival. Following each session, patients rated the alliance with their therapists using the Working Alliance Inventory [8], in which we focused on the bond subscale to assess the strength of the emotional bond. All sessions were videotaped. The Rupture Resolution Rating System [9] was used to code 2 types of ruptures: confrontational (patients express anger toward the therapist or discontent) and withdrawal (patients avoid expressing dissatisfaction or some other aspect of their experience with the therapists). Using the Rupture Resolution Rating System, coders also coded the therapists’ attempts to repair the ruptures resorting to various resolution strategies. Each session was coded by 2 trained independent coders, showing high reliability between them (ICC2, 1: confrontation = 0.90, withdrawal = 0.95, resolution = 0.94). The data were hierarchically nested (assessments within patients); thus, we used the SAS PROC MIXED procedure for multilevel modeling and added the patient as a random effect. First, to examine whether OT increased significantly during therapy sessions, we estimated the means of OT changes from preto postsession assessment using multilevel analyses, predicting changes in OT with an intercept only. Second, we examined the associations between changes in OT and patient-rated bond, as well as observer-rated rupture and resolution episodes across treatment, controlling for the fixed effect of time. Because it has been demonstrated that the salience effect of OT depends on baseline individual differences [2], we used centering to disentangle differences in the tendency to show changes in OT across experiences from within-patient processes. Findings show that the levels of OT increased significantly during psychotherapy sessions, with an estimated mean change of 0.82 (SD = 1.01, t21 = 5.01, p < 0.0001). Table 1 shows that a larger increase in OT levels during the sessions was associated with more instances of conflict and rupture in the alliance with the therapist, as manifested in (a) greater increases in confrontation ruptures Although the effects of change in oxytocin (OT; a 9-aminoacid cyclic neuropeptide produced in the paraventricular nucleus of the hypothalamus) during social and intimate interactions are well established, little is known about OT function during psychotherapy sessions. Based on the recent literature on OT in interpersonal interactions, demonstrating increased levels during close interpersonal contact and exposure to emotionally loaded stimuli [1], OT levels are expected to increase during psychotherapy sessions. Based on contemporary theories and research on the overarching role of OT in regulating social cues of rewarding and conflictual/aggressive experiences [2], OT levels are expected to show an even greater increase during sessions that include salient interpersonal interactions, as in the case of major gains or ruptures in the working alliance with the therapists. In the present work we focused on major ruptures in the working relationship, as their importance has been repeatedly argued in the theoretical literature and demonstrated empirically [3, 4]. We expected OT levels to show greater increases during sessions that include ruptures in the alliance, as assessed by (a) drops in the strength of the patientrated alliance and (b) external behavioral coding of alliance ruptures. Study setting and participants are described in detail elsewhere [5, and at clinicaltrials.gov identifier: NCT02728557]. Patients diagnosed with major depressive disorder (n = 22) were randomized to one of two 16-session manualized short-term psychodynamic treatments, supportive-expressive or supportive, as part of an ongoing randomized control trial. The mean age was 30.22 years (SD = 7.30), and 14 participants were female. Twelve had a comorbid personality disorder. The patients’ mean score on the 17-item Hamilton Rating Scale [6] at intake was 21.40 (SD = 3.92). The study was approved by the Institutional Review Board, and all patients gave informed consent in writing before screening. The treating psychotherapists had a mean of 10.94 years of experience. A total of 172 saliva samples were collected, before and after treatment sessions 4, 8, 12, and 16. The concentrations of salivary OT were quantified by radioimmunoassay. Although the physiological role of OT in saliva and its link with plasma OT is not entirely clear, studies have repeatedly documented detectable concentrations of OT in saliva associated with increased intimacy and affiliation [7]. Participants were asked to refrain from eating and Received: October 20, 2017 Accepted: January 25, 2018 Published online: March 6, 2018

Tohar Dolev

Papers

Identifying the most suitable treatment for depression based on patients’ attachment: study protocol for a randomized controlled trial of supportive-expressive vs. supportive treatments

Tourism and depressive symptoms

Patient demographics and psychological functioning as predictors of unilateral termination of psychodynamic therapy.

Oxytocin as a Neurobiological Marker of Ruptures in the Working Alliance.

Changes in causal attributions and relationship representations: Are they specific or common mechanisms in the treatment of depression?