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Per Høglend, research director Svein Amlo, clinical director Alice Marble Kjell-Petter Bøgwald Øystein Sørbye Mary C PowerPoint Presentation
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FEST - First Experimental Study of Transference-interpretations. FEST - First Experimental Study of Transference-interpretations. Per Høglend, research director Svein Amlo, clinical director Alice Marble Kjell-Petter Bøgwald Øystein Sørbye Mary Cosgrove Sjaastad Oscar Heyerdahl

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slide1

FEST - First Experimental Study of Transference-interpretations

FEST - First Experimental Study of Transference-interpretations

Per Høglend, research director

Svein Amlo, clinical director

Alice Marble

Kjell-Petter Bøgwald

Øystein Sørbye

Mary Cosgrove Sjaastad

Oscar Heyerdahl

Paul Johansson

Randi Ulberg

Martin M. Nilsen

Martin Furan

Knut Hagtvet

Jan Ivar Røssberg

Per Høglend, research director

Svein Amlo, clinical director

Alice Marble

Kjell-Petter Bøgwald

Øystein Sørbye

Mary Cosgrove Sjaastad

Oscar Heyerdahl

Paul Johansson

Randi UlbergMartin M. Nilsen

Martin Furan

Knut Hagtvet

Jan Ivar Røssberg

Hanne-Sofie Dahl

Anne Grethe Hersoug

John Christopher Perry

Diakonhjemmet Hospital, Oslo

Blakstad Hospital, Akershus

Ullevål University Hospital, Division of Psychiatry

Ullevål University Hospital,

Centre for Child and Adolescent Psychiatry

Department of Psychology, University of Oslo

Department of Psychiatry

Department ofPsychiatry

dora case
Dora Case

Høglend et al. 2006 American Journal of Psychiatry

Høglend et al. 2008 American Journal of Psychiatry

Ulberg et al. 2009 Canadian journal of Psychiatry

positive studies
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
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
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
slide7
So we see that you avoid talking about this

DEFENCE

Psychodynamicinterpretation

because you feel anxious and uncomfortable

ANXIETY

discussing your sadness and anger over

IMPULSE

your fathers death.

PARENTS

You did the same after your divorce

OTHERS

and again now that we are ending therapy

THERAPIST

Defence Anxiety

Parents Others

Impulse

Therapist

psychodynamic functioning scales pfs
Psychodynamic Functioning Scales ( PFS)
  • Quality of Family relationships 1 - 100
  • Quality of Friendships 1 - 100
  • Quality of Romantic Relations 1 - 100
  • Tolerance for Affects 1 - 100
  • Insight 1 - 100
  • Problem solving Capacity 1 - 100
  • Overal Psychodynamic Functioning is the simple weighted average of the six scales.
  • Reliability for average scores of three expert raters:
    • status scores = 0.91
    • change scores( relative interpretation) = 0.82
    • change scores (absolute interpretation) = 0.94
specific techniques
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
slide11
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 %

Pretreatment characteristics of patients who received dynamic psycho-therapy of one year duration with (N=52) and without (N=48) transference interpretations.

treatment integrity sessions rated 452
Trans. interpretations ( 4 items)***

Extra-transference interpr. (5 items)***

Supportive ( 7 items)

General skill (8 items)

Transference Comparison

1.7 (0.7) 0.1 (0.2)

2.4 (0.5) 2.7 (0.6)

0.7 (0.3) 0.7 (0.3)

3.6 (.0.2) 3.6 (0.3)

Treatment integrity (Sessions rated = 452)

Scale format: No emphasis Minor Moderate Considerable Major emph.

0 1 2 3 4

C

T

quality of object relations
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 posttreatment pfs outcome
The proportion of patients recovered at posttreatmentPFS outcome

GAF>61 GAF< 61**

N = 24 27 24 24

slide15
The proportion of patients recovered on both the primary outcome measures (PFS, IIP) at three year follow-up

High QOR Low QOR

N = 29 26 19 25

slide16
3. Mediatoranalysis:What is the mechanism linking transference interpretation to long-term improvement of interpersonnal function?

?

Resultat

Mediator

Psykoterapi

slide17
FEST

Mediated moderation

Insight pre –

3 year follow-up

Time x Treat (low QOR)

1,2 (p=0,04)

Insight 0,6 (p=0,000)

Insight x QOR 0,1 (p=0,06)

Time x Treat (low QOR)

1,2 (p=0,03)

Time x Treat (low QOR)

0,3 (non-significant)

Transference/

Non-transference

Interpersonal pre-

3 year follow-up

Linear mixed models, log time

follow up period 3 years pd subsample n 45
Follow-up period 3 yearsPD subsample (N=45)
  • Transference Comparison
  • N=22 N=23
  • General practitioners
  • Any 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
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
treatment
Treatment
  • Initial phase
  • Patient: 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 know
  • Therapist. No, but may be you get disappointed, withdraws, overeats instead of feeling that you are angry with me for not helping out.
slide27
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 75
  • Became 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
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.