The Ghent Psychotherapy Study: A Pragmatic, Stratified, Randomized Parallel Trial into the Differential Efficacy of Psychodynamic and Cognitive-Behavioral Interventions in Dependent and Self-Critical Depressive Patients.

INTRODUCTION: Different types of psychotherapy are effective for treating major depressive disorder across groups yet show large within-group differences. Patient personality style is considered a potentially useful variable for treatment matching. OBJECTIVE: This study is the first experimental test of the interaction between therapeutic approach and patients' dependent versus self-critical personality styles. METHODS: A pragmatic stratified parallel trial was carried out with 100 adult patients diagnosed with DSM-IV-TR major depressive disorder. They were randomly assigned to short-term (16-20 sessions) cognitive behavioral therapy (CBT) or short-term psychodynamic psychotherapy (STPP). Patients were assessed at baseline, during therapy, post-therapy, and at 3- and 6-month follow-up. Primary outcome is depression severity measured by the Hamilton Rating Scale for Depression posttreatment. Primary analysis was by intention to treat. This trial is registered with the ISRCTN registry (www.isrctn.com), number ISRCTN17130982. RESULTS: The intention-to-treat sample consisted of 100 participants; 40 with self-critical and 60 with dependent personality styles were randomized to either CBT (n = 50) or STPP (n = 50). We observed no interaction effect (-0.34 [-6.14, 5.46]) between therapy and personality style and found no evidence for a difference in effectiveness between the treatments in general in terms of symptom reduction and maintained benefits at 6-month follow-up. CONCLUSION: We found no evidence that dependent versus self-critical personality styles moderate the relation between treatment and outcome in depression. Research using individual patient data could gain further insight into why specific therapeutic approaches work better for specific patients.

Beyond Clinical Case Studies in Psychoanalysis: A Review of Psychoanalytic Empirical Single Case Studies Published in ISI-Ranked Journals.

Single case studies are at the origin of both theory development and research in the field of psychoanalysis and psychotherapy. While clinical case studies are the hallmark of psychoanalytic theory and practice, their scientific value has been strongly criticized. To address problems with the subjective bias of retrospective therapist reports and uncontrollability of clinical case studies, systematic approaches to investigate psychotherapy process and outcome at the level of the single case have been developed. Such empirical case studies are also able to bridge the famous gap between academic research and clinical practice as they provide clinically relevant insights into how psychotherapy works. This study presents a review of psychoanalytic empirical case studies published in ISI-ranked journals and maps the characteristics of the study, therapist, patient en therapies that are investigated. Empirical case studies increased in quantity and quality (amount of information and systematization) over time. While future studies could pay more attention to providing contextual information on therapist characteristics and informed consent considerations, the available literature provides a basis to conduct meta-studies of single cases and as such contribute to knowledge aggregation.

Interactions between Obsessional Symptoms and Interpersonal Ambivalences in Psychodynamic Therapy: An Empirical Case Study.

The classical symptom specificity hypothesis (Blatt, 1974) particularly associates obsessional symptoms to interpersonal behavior directed at autonomy and separation from others. Cross-sectional group research, however, has yielded inconsistent findings on this predicted association, and a previous empirical case study (Cornelis et al., in press; see Chapter 2) documented obsessional pathology to be rooted in profound ambivalences between autonomous and dependent interpersonal dynamics. Therefore, in the present empirical case study, concrete operationalizations of the classical symptom specificity hypothesis are contrasted to alternative hypotheses based on the observed complexities in Chapter 2. Dynamic associations between obsessional symptoms and interpersonal functioning is further explored, aiming at further contribution to theory building (i.e., through suggestions for potential hypothesis-refinement; Stiles, 2009). Similar to the first empirical case study (Chapter 1), Consensual Qualitative Research for Case studies is used to quantitatively and qualitatively describe the longitudinal, clinical interplay between obsessional symptoms and interpersonal dynamics throughout the process of supportive-expressive psychodynamic therapy. In line with findings from Chapter 1, findings reveal close associations between obsessions and interpersonal dynamics, and therapist interventions focusing on interpersonal conflicts are documented as related to interpersonal and symptomatic alterations. Observations predominantly accord to the ambivalence-hypothesis rather than to the classical symptom specificity hypothesis. Yet, meaningful differences are observed in concrete manifestations of interpersonal ambivalences within significant relationships. Findings are again discussed in light of conceptual and methodological considerations; and limitations and future research indications are addressed.

The Ghent Psychotherapy Study (GPS) on the differential efficacy of supportive-expressive and cognitive behavioral interventions in dependent and self-critical depressive patients: study protocol for a randomized controlled trial.

BACKGROUND: Major depressive disorder is a leading cause of disease burden worldwide, indicating the importance of effective therapies. Outcome studies have shown overall efficacy of different types of psychotherapy across groups, yet large variability within groups. Although patient characteristics are considered crucial in understanding outcome, they have received limited research attention. This trial aims at investigating the interaction between therapeutic approach (pre-structured versus explorative) and the personality style of patients (dependent versus self-critical), which is considered a core underlying dimension of depressive pathology. METHODS/DESIGN: This study is a pragmatic stratified (dependent and self-critical patients) parallel trial with equal randomization (allocation 1:1) conducted in Flanders, Belgium. One hundred and four patients will be recruited and randomized to either 16-20 sessions of cognitive behavioral therapy for depression (pre-structured approach) or 16-20 sessions of short-term psychodynamic psychotherapy for depression (explorative approach) conducted by trained psychotherapists in private practices. The primary outcome is the severity of depression as measured by the Hamilton Rating Scale for Depression at completion of therapy. Secondary outcome measures include self-reported depressive and other symptoms, interpersonal functioning, idiosyncratic complaints, and the presence of the diagnosis of depression. Additional measures include biological measures, narrative material (sessions, interviews), and health care costs. DISCUSSION: This trial presents the test of an often-described, yet hardly investigated interaction between important personality dimensions and therapeutic approach in the treatment of depression. Results could inform therapists on how to match psychotherapeutic treatments to specific personality characteristics of their patients. TRIAL REGISTRATION: Isrctn.com, ISRCTN17130982 . Registered on 2 February 2015.

Theoretical pluralism in psychoanalytic case studies.

The aim of this study is to provide an overview of the scientific activity of different psychoanalytic schools of thought in terms of the content and production of case studies published on ISI Web of Knowledge. Between March 2013 and November 2013, we contacted all case study authors included in the online archive of psychoanalytic and psychodynamic case studies (www.singlecasearchive.com) to inquire about their psychoanalytic orientation during their work with the patient. The response rate for this study was 45%. It appears that the two oldest psychoanalytic schools, Object-relations psychoanalysis and Ego psychology or "Classical psychoanalysis" dominate the literature of published case studies. However, most authors stated that they feel attached to two or more psychoanalytic schools of thought. This confirms that the theoretical pluralism in psychoanalysis stretches to the field of single case studies. The single case studies of each psychoanalytic school are described separately in terms of methodology, patient, therapist, or treatment features. We conclude that published case studies features are fairly similar across different psychoanalytic schools. The results of this study are not representative of all psychoanalytic schools, as some do not publish their work in ISI ranked journals.

Measurement equivalence of the Toronto Structured Interview for Alexithymia across language, gender, and clinical status.

The Toronto Structured Interview for Alexithymia (TSIA) has been translated into Dutch, German, and Italian and validated in clinical and nonclinical populations. In order to make valid comparisons across different population groups, it is important to establish measurement equivalence across variables such as language, gender, and clinical status. Our objective in this study was to establish measurement equivalence in relation to language (English, Dutch, German, and Italian), gender, and clinical status (non-clinical, psychiatric, and medical) using differential item functioning (DIF). The sample was composed of 842 adults representing the four language groups, all of whom had undergone the TSIA assessment as part of several earlier studies. Ordinal Logistic Regression was employed to explore DIF of the TSIA items. Although several items were found to exhibit DIF for language, gender, or clinical status, all of these effects were within an acceptable range. These findings provide support for the measurement equivalence of the TSIA, and allow researchers to reliably compare results from studies using the TSIA across the four language groups, gender, and clinical status.

Research on Balint groups: A literature review.

OBJECTIVE: As the scientific literature on Balint groups (BGs) is scattered, this paper provides an overview of the literature on BGs published in peer-reviewed journals. Study characteristics are analyzed and the principal research topics are discussed. METHODS: 'Web of Science' and 'Pubmed' databases were searched and all English-language studies on BGs (empirical and non-empirical) were included. RESULTS: Of the 94 articles included, 35 are empirical studies adopting a qualitative, quantitative or mixed methodology. The research topics that emerged include outcome, characteristics of BG participants, themes addressed in BGs, BG processes, leadership and BG evaluations. The remaining articles were classified as historical articles, reports and reflective articles, for which the main discussion themes are presented. CONCLUSION: Research on BGs proves to be diverse, scarce and often methodologically weak. However, indications of the value of BG work were found. Therefore, further research is strongly indicated. PRACTICE IMPLICATIONS: Points of interest that could to be further considered by BG workers and researchers are for instance long-term BG participation and 'modified Balint groups'. Recommendations for future research on BGs are provided.

A metasynthesis of published case studies through Lacan's L-schema: Transference in perversion.

Transference in perversion is characterized by specific problems such as a defiant and polemic attitude, erotic transference, projections, and aggression. Such transference poses particular problems in the treatment of perversion and might render analytical work with these patients impossible. The authors propose that Lacan's L-schema can contribute to separating productive from counterproductive aspects of transference as it distinguishes between an Imaginary and a Symbolic dimension in transference. In this meta-synthesis of 11 published case studies on sexual perversion, patterns of transference are analysed. On the Imaginary dimension, the authors found that patients with perversion tend to (un)consciously engage the analyst in a relationship characterized by identification, fusion and rivalry. On the Symbolic dimension, they found that perverse patients are able to question their motives, lapses, symptoms, and subjective identity. The thematic analysis revealed the importance of the position of the analyst in this work, which is described within the L-schema as being the representative of the otherness in the Other. Implications for clinical practice and recommendations for further research are outlined.

A Lacanian view on Balint group meetings: a qualitative analysis of two case presentations.

BACKGROUND: GPs' subjectivity is an intrinsic instrument in their daily work. By offering GPs a platform to present and discuss difficult interactions with patients, Balint group work be might provide them an opportunity to explore and articulate aspects of their subjectivity. In order to get a more profound understanding of what participation in a Balint group can offer, we focused on the process of change that can be observed during Balint group meetings. To that end, this study scrutinized two Balint group case discussions on a micro-level. METHOD: Two cases were selected from a larger data set of 68 audio-taped case discussions in four Balint groups. In order to shed light on the type of change that characterizes the presenter's narrative, we used Lacan's theoretical distinction between imaginary and symbolic modes of relating to the other. RESULTS: In both case discussions, the GPs presenting the case initially appeared to be stuck in a fixed image of a situation, referred to as 'imaginary relating to the other.' Through a range of interactions with the group, the presenters were encouraged to explore different subject positions, which allowed them to broaden their initial image of the situation and to discover other issues at stake. This was referred to as a more symbolic way of relating to the other. CONCLUSION: This study throws light on the type of change Balint group participation allows for and on the way this might be achieved. We conclude that Balint group work is potentially beneficial to the participating GPs as well as to the relationship with their patients.

Interpersonal problems and cognitive characteristics of interpersonal representations in alexithymia: a study using a self-report and interview-based measure of alexithymia.

In this study, associations between alexithymia, interpersonal problems, and cognitive-structural aspects of internal interpersonal representations were examined. Alexithymia was measured using the Toronto Structured Interview for Alexithymia (TSIA) and the 20-item Toronto Alexithymia Scale (TAS-20). To measure interpersonal problems, the dominance and affiliation dimension scores of the Inventory of Interpersonal Problems were used, and cognitive-structural characteristics of interpersonal representations were measured using the Social Cognition and Object Relations Scale (SCORS). As hypothesized, alexithymia was related to cold and withdrawn, but not to dominant or submissive, interpersonal functioning. In terms of the SCORS, alexithymia was negatively related to complexity of interpersonal representations, both in TAT and in interview narratives, indicating a link between alexithymia and mentalization. However, alexithymia was related only to the dimension of social causality when this dimension was scored on TAT narratives. Overall, the TSIA provides the most consistent and stable results after controlling for negative affectivity.

The assessment of the social cognition and object relations scale on TAT and interview data.

This study examines the reliability and convergent validity of 2 versions of the Social Cognition and Object Relations Scale (SCORS), one for use with Thematic Apperception Test narratives (SCORS-TAT; Westen, 1990) and one for use with clinical interview data (SCORS-CDI; Westen, Barends, Leigh, Mendel, & Silbert, 1990 ). Four SCORS dimensions were evaluated. Data were collected in a psychiatric sample (N = 74). Results show that although interrater reliability was good for all dimensions, internal consistency was low, especially for the affective dimensions. Structural equation modeling, in which a model with 2 factors (i.e., SCORS-TAT and SCORS-CDI) and 4 dimensions each was tested, indicated low convergence between corresponding dimensions of SCORS-TAT and SCORS-CDI. Correlational analyses suggested that this was due to a strong method factor. Regression analyses, however, revealed that the presence of a personality disorder operated as a moderator for convergence between corresponding cognitive-structural dimensions.

The Observer Alexithymia Scale: a reliable and valid alternative for alexithymia measurement?

In this study, we evaluated the reliability and validity of the Dutch version of the Observer Alexithymia Scale (OAS; Haviland, Warren, & Riggs, 2000) while addressing shortcomings of earlier research. Internal consistency and test-retest reliability were found to be adequate, whereas interrater reliability was insufficient. The original five-factor model (Distant, Uninsightful, Somatizing, Humorless, Rigid) with item parcels showed excellent fit, indicating adequate translation. Alternative models were tested to overcome problems with the parcel method, and all showed poor fit. OAS total scores correlated .23 with the 20-item Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994; Bagby, Taylor, & Parker, 1994) and .50 with the Toronto Structured Interview for Alexithymia (Bagby, Taylor, Parker, & Dickens, 2006). These problematic results on validity compromise the use of the OAS as an alexithymia measure.

Does the 20-item Toronto Alexithymia Scale measure alexithymia? A study of natural language use.

Construct validity of the 20-item Toronto Alexithymia Scale (TAS-20) was investigated by analyzing natural language use. It was hypothesized that the TAS-20 should be related to a lower use of emotion words and fewer references to social processes. 32 clinical interviews with mental health outpatients were analyzed with four categories of the computerized Linguistic Inquiry and Word Count dictionary: positive emotions, negative emotions, references to others, and communication words. The Difficulty Identifying Feelings subscale was positively related to negative emotion words, the Difficulty Describing Feelings subscale showed no relevant associations, and the Externally Oriented Thinking subscale was related to reduced use of positive emotion words and social process words. It is concluded that in this sample, the Externally Oriented Thinking subscale provides the best operationalization of the alexithymia construct.