per høglend, research director svein amlo, clinical director alice marble kjell-petter bøgwald...
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Per Høglend, research directorPer Høglend, research directorSvein Amlo, clinical directorSvein Amlo, clinical directorAlice MarbleAlice MarbleKjell-Petter BøgwaldKjell-Petter BøgwaldØystein SørbyeØystein SørbyeMary Cosgrove SjaastadMary Cosgrove SjaastadOscar HeyerdahlOscar HeyerdahlPaul JohanssonPaul JohanssonRandi UlbergRandi Ulberg Martin M. NilsenMartin M. NilsenMartin FuranMartin FuranKnut HagtvetKnut HagtvetJan Ivar RøssbergJan Ivar Røssberg
FEST - First Experimental Study of Transference-interpretations
Department of PsychiatryDiakonhjemmet Hospital, OsloBlakstad Hospital, Akershus
Ullevål University Hospital, Division of PsychiatryUllevål University Hospital,
Centre for Child and Adolescent PsychiatryDepartment of Psychology, University of Oslo
Per Høglend, research directorPer Høglend, research directorSvein Amlo, clinical directorSvein Amlo, clinical directorAlice MarbleAlice MarbleKjell-Petter BøgwaldKjell-Petter BøgwaldØystein SørbyeØystein SørbyeMary Cosgrove SjaastadMary Cosgrove SjaastadOscar HeyerdahlOscar HeyerdahlPaul JohanssonPaul JohanssonRandi UlbergRandi Ulberg Martin M. NilsenMartin M. NilsenMartin FuranMartin FuranKnut HagtvetKnut HagtvetJan Ivar RøssbergJan Ivar RøssbergHanne-Sofie DahlHanne-Sofie DahlAnne Grethe HersougAnne Grethe HersougJohn Christopher PerryJohn Christopher Perry
FEST - First Experimental Study of Transference-interpretations
Department of Psychiatry
Dora Case
Høglend et al. 2006 American Journal of PsychiatryHøglend et al. 2008 American Journal of PsychiatryUlberg et al. 2009 Canadian journal of Psychiatry
Positive studies
Gabbard et al. 1994: ”Transference interpretation is is high gain high risk” Malan: 1976 Marziali: Positive association on 1 of 7 variables
Negative studies:
8 on outcome: 4 neg.correlations trans. Int. outcome 4 non.sign. association
10 on in-session effects: alliance, defensiveness, involvement, opposition, silence, drop-out
Within-group correlations
High QOR Transference group (N=26)
PFS IIP GAF GSI
Early transference
interpretations 0.30 0.12 0.18 0.35
Low QOR Transference goup (N=24)
Early transference
interpretations -0.40* -0.17 -0.29 -0.03
FEST 1994 -2004
Randomized Clinical Trial with Dismantling design
100 patients randomized to one year psychodynamic psychotherapy with and without transference interpretation
All therapists did both treatments
They were trained for up to 4 years
So we see that you avoid talking about thisSo we see that you avoid talking about this DEFENCEDEFENCE
Psychodynamic interpretation
Defence Anxiety
Impulse
Parents Others
Therapist
ANXIETY
IMPULSE
PARENTS
OTHERS
THERAPIST
because you feel anxious and uncomfortable
discussing your sadness and anger over
your fathers death.
You did the same after your divorce
and again now that we are ending therapy
Psychodynamic Functioning Scales ( PFS)Psychodynamic Functioning Scales ( PFS)
Quality of Family relationships Quality of Family relationships 1 - 1001 - 100Quality of Friendships Quality of Friendships 1 - 1001 - 100Quality of Romantic Relations Quality of Romantic Relations 1 - 1001 - 100Tolerance for Affects Tolerance for Affects 1 - 1001 - 100Insight Insight 1 - 1001 - 100Problem solving Capacity Problem solving Capacity 1 - 1001 - 100
Overal Psychodynamic Functioning is the simple weighted average Overal Psychodynamic Functioning is the simple weighted average of the six scales.of the six scales.
Reliability for average scores of three expert raters: Reliability for average scores of three expert raters: – status scores = 0.91 status scores = 0.91 – change scores( relative interpretation) = 0.82 change scores( relative interpretation) = 0.82 – change scores (absolute interpretation) = 0.94change scores (absolute interpretation) = 0.94
Specific Techniques
1.Therapist addresses transactions in the patient-therapist relationship
2. Therapist encourages exploration of thoughts and feelings about the therapy and the therapist and repercussions on transference by high therapist activity
3 .The therapist encourages the patient to discuss how the therapist might feel or think about the patient
4. The therapist explicitely includes himself in interpretive linking of dynamic elements (conflicts), direct manifestations of transference, allusions to the transference,
5. The therapist interprets repetitive interpersonal patterns, including genetic interpretations, and links to transference
Pretreatment characteristics of patients who received dynamic psycho-therapy of one year duration with (N=52) and without (N=48) transference interpretations.
Age
Global optimism **
Expectancy
Motivation
Quality of Object relations
Female sex
Single
Depressive disorders
Anxiety disorders
Other
No diagnosis
Personality disorders
More than one pers.dis.
Transference Comparison
38 (9) 36 (10)
61 (14) 69 (13)
8 (2) 8 (2)
5.4 (0.6) 5.4 (0.6)
5.1 (0.8) 5.1 (0.8)
50 % 63 %
38 % 54 %
50 % 52 %
26 % 23 %
14 % 17 %
17 % 19 %
44 % 46 %
19 % 19 %
Treatment integrity (Sessions rated = 452)Treatment integrity (Sessions rated = 452)
Trans. interpretations ( 4 items)*** Trans. interpretations ( 4 items)***
Extra-transference interpr. (5 items)***Extra-transference interpr. (5 items)***
Supportive ( 7 items)Supportive ( 7 items)
General skill (8 items) General skill (8 items)
Transference ComparisonTransference Comparison
1.7 (0.7) 0.1 (0.2)1.7 (0.7) 0.1 (0.2)
2.4 (0.5) 2.7 (0.6)2.4 (0.5) 2.7 (0.6)
0.7 (0.3) 0.7 (0.3)0.7 (0.3) 0.7 (0.3)
3.6 (.0.2) 3.6 (0.3) 3.6 (.0.2) 3.6 (0.3)
Scale format: No emphasis Minor Moderate Considerable Major emph. 0 1 2 3 4
TC
Quality of Object Relations
Lifelong pattern of relationships from primitive to mature
7-8: Mature equitable relationships
5-6: Recent relationships may be difficult, but there are evidence of at least one mature relationship in the patients history
3-4:Need of dependency or overcontrol in most relationships
1-2: Unstable, less gratifying relationships
The proportion of patients recovered at posttreatmentPFS outcome
GAF>61 GAF< 61**
N = 24 27 24 24
0
10
20
30
40
50
60
ComparisonTransference
The proportion of patients recovered on both the The proportion of patients recovered on both the primary outcome measures (PFS, IIP) at three year primary outcome measures (PFS, IIP) at three year
follow-upfollow-up
0
5
10
15
20
25
30
35
40
ComparisonTransference
High QOR Low QOR
N = 29 26 19 25
Psykoterapi
Mediator
Resultat
3. Mediatoranalysis:What is the mechanism linking transference interpretation
to long-term improvement of interpersonnal function?
?
FEST
Mediated moderation
Transference/Non-transference
Insight pre – 3 year follow-up
Interpersonal pre- 3 year follow-up
Insight 0,6 (p=0,000)Insight x QOR 0,1 (p=0,06)
Linear mixed models, log time
Time x Treat (low QOR)1,2 (p=0,04)
Time x Treat (low QOR)1,2 (p=0,03)
Time x Treat (low QOR)0,3 (non-significant)
Follow-up period 3 yearsPD subsample (N=45)
Transference Comparison N=22 N=23 General practitionersAny treatment 60%** 90%Antidepressant medication 30%* 57%Hospitalized 0% 13%Sick leave 10%* 38% Specialist treatment
Any treatment 20%** 52%Additional psychother. 20%** 48%Antidepressive medication 20%** 48%
40 year old female
Depression and bulimia
Living with her fouth partner, contemplating leaving him
Verbally aggressive father, mother alcoholic
Talent in sport provided self esteem
Difficulties expressing her feelings and opinions, rather asks for help
After disagreements binge eating and purging alternating with very strict diet
TreatmentInitial phasePatient: I’m not sure what to takk about. Whhat can I ask from oothers, like with my childern, and wonder what other people would do.Therapist: Can you imagine me having an opinion on this ?Patient: If I can think of what you would do ? I don’t get answers here.Therapist: How doo you feel about that ?Patient: Don’t knowTherapist. No, but may be you get disappointed, withdraws, overeats instead of feeling that you are angry with me for not helping out.
As therapy progressed, the patient more often expressed her own points of view
Therapist: Hoow do you feel about me, leading you on to thin ice so to speak, pointing out that you don’t say what you mean or how you feel ?
Patient: I’m not sure how I feel. I see that i suddenly changed and became a bit more opinionated. So why not try somthing in between ?
At posttreatment: Insight increased from 63 to 75Became aware of how much she automatically disawoved her own feelings, especiallly negative ones. She now saw the connection between specific stressors, negative emotions, binge eating and how it interfered with her daily life. She had become aware of how she repeated her feeling towards her parents, her partners, friends and also the therapist.
At 3-years follow up: Recovered on all outcome variables. GAF, GSI, IIP, and The Psychodynamic Functioning Scales (PFS)
Patients increase insight from 62 to 74
62: tendency to blame self or other to much too much in disputes. Unclear, ”learned ” or somewhat stereotyped awareness of connections between past and present experiences. In some areas attitudes, needs, behaviours and coping seem unrecognized,automatic, and stress reactions comme as a surprise. Understands that symptoms is a sign of disturbance.
74: Can account for the most important inner conflicts and motives, related problems and repetitive behavior interpersonal patterns. May blame self or others too much after disputes, but observes own reactions and learn froom it (integration). Generally curious and tolerant, realistic expectations about the future.