Psychodynamic Group Therapy Research Articles

Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in female outpatients with anorexia nervosa (ANTOP study): 5-year follow-up of a randomised controlled trial in Germany

Anorexia nervosa is a serious illness leading to substantial morbidity and mortality. The Anorexia Nervosa Treatment of Outpatients (ANTOP) study is the largest randomised controlled trial (RCT) globally that uses psychotherapy in outpatients with anorexia nervosa. In this Article, we report the results of the 5-year follow-up. The ANTOP study is an open-label, multicentre RCT involving 242 adult female outpatients with anorexia nervosa. Participants were recruited from ten university hospitals in Germany, had to be aged at least 18 years and female, and have a diagnosis of anorexia nervosa with a body-mass index (BMI) of 15·0-18·5 kg/m2. Participants were randomly allocated (1:1:1) to 10 months of treatment with focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual; complete masking of the participants was not possible. The mean duration of the follow-up was 5·96 years (SD 0·2) after randomisation. The primary outcome was change in BMI from baseline at the end of treatment; here, we present the change in BMI from baseline to the 5-year follow-up, using an intention-to-treat approach with a mixed model for repeated measurements. Groups were also compared according to global outcome (based on the combination of BMI and measures of anorexia severity), eating pathology (based on the Eating Disorder Inventory 2), and other secondary mental health outcomes. We did a linear regression analysis to identify the predictors of BMI at follow-up. Between May, 2007, and June, 2009, we screened 727 patients for eligibility; at baseline, 242 patients with a mean BMI of 16·7 kg/m2 (SD 1·0) were included and randomly allocated to 10 months of treatment with focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual. 154 (64%) of 242 patients completed the 5-year follow-up assessment (53 [66%] of 80 in the focal psychodynamic therapy group, 55 [69%] of 80 in the enhanced cognitive behaviour therapy group, and 46 [56%] of 82 in the optimised treatment-as-usual group), with a mean age of 32·4 years; all reported their ethnicity as White. At the 5-year follow-up, there was an improvement in mean BMI, eating pathology, and global outcome in all treatment groups with no significant differences between treatment groups. Estimated mean BMI was: 18·64 kg/m2 (95% CI 18·07-19·21) in the focal psychodynamic therapy group (with an estimated mean BMI gain from baseline to 5-year follow-up of 1·91 kg/m2 [1·34-2·48]); 18·70 kg/m2 (18·15-19·25) in the enhanced cognitive behaviour therapy group (with an estimated mean BMI gain of 1·98 kg/m2 [1·43-2·53]); and 18·99 kg/m2 (18·39-19·59) in the optimised treatment-as-usual group (with an estimated mean BMI gain of 2·26 kg/m2 [1·67-2·86]). There were no significant differences between treatment groups regarding BMI at the 5-year follow-up; the estimated difference was -0·06 (-0·85 to 0·73) between the focal psychodynamic therapy and enhanced cognitive behaviour therapy groups; -0·35 (-1·18 to 0·47) between the focal psychodynamic therapy and optimised treatment-as-usual groups; and -0·29 (-1·10 to 0·52) between the enhanced cognitive behaviour therapy and optimised treatment-as-usual groups. On the basis of observed data, global outcome at the 5-year follow-up showed 41% (33-49) full recoveries, 41% (33-49) partial recoveries, and 18% (12-24) with full-syndrome anorexia nervosa. One patient initially treated in the enhanced cognitive behaviour therapy group died by suicide between the 1-year and 5-year follow-up. BMI at the 5-year follow-up was predicted by BMI at baseline (p=0·0021), illness duration (p=0·0004), and depression at baseline (p=0·012). The long-term results of the ANTOP trial confirm the improvement in BMI of patients with anorexia nervosa in all groups; however, a substantial proportion of patients had a poor global outcome. The predictors for the long-term course of anorexia nervosa in our ANTOP study show that we need to treat patients with anorexia nervosa at an earlier stage of the disease, with a clear focus on weight gain and considering other comorbidities (especially depression). German Federal Ministry of Education and Research.

Selbstöffnung und interpersonaler Input in der psychodynamischen Gruppenpsychotherapie – Eine explorative Studie

In the present explorative data analysis, for the first time possible, coherences were identified for “interpersonal input” and “self-disclosure”, – two factors which are highly important in the context of psychodynamic group research. 51 videotapes, each documenting 90 minutes of a total of three outpatient psychodynamic group therapy sessions, were analyzed with the help of SYMLOG. Results may show the tendency of the importance of receiving statements that promote mentalization as well as directly received speeches as predictors for both factors.

Causal inference under interference with prognostic scores for dynamic group therapy studies.

Group therapy is a common treatment modality for behavioral health conditions. Patients often enter and exit groups on an ongoing basis, leading to dynamic therapy groups. Examining the effect of high versus low session attendance on patient outcomes is a research question of interest. However, there are several challenges to identifying causal effects in this setting, including the lack of randomization, interference among patients, and the interrelatedness of patient participation. Dynamic therapy groups motivate a unique causal inference scenario, as the treatment statuses are completely defined by the patient attendance record for the therapy session, which is also the structure inducing interference. We adopt the Rubin causal model framework to define the causal effect of high versus low session attendance of group therapy at both the individual patient and peer levels. We propose a strategy to identify individual, peer, and total effects of high attendance versus low attendance on patient outcomes by the prognostic score stratification. We examine performance of our approach via simulation and apply it to data from a group cognitive behavioral therapy trial for treating depression among patients in a substance use disorders treatment setting.

Rupture and Repair: Using Leader Errors in Psychodynamic Group Psychotherapy

ABSTRACT The therapeutic alliance is the bedrock upon which psychotherapy rests. Therapists need be aware of ruptures in the alliance, especially those caused by the therapist. Much important therapeutic work occurs in repairing alliance ruptures.

Short-term focused group-analytic psychotherapy (SFGAP): An integrative approach to change based on research

Group-Analytic Psychotherapy (Group Analysis; GA) is probably the most commonly used psychodynamic group therapy in Europe. It is mainly based on clinical experience, but the research evidence is increasing. This article describes how results from a Randomized Clinical Trial (RCT) comparing the outcomes of short- (20 sessions; six months) and long-term (80 sessions; two years) group-analytic, manualized therapies, are integrated with the short-term therapy used in this RCT, resulting in a new brand of therapy, Short-Term Focused Group-Analytic Psychotherapy (SFGAP). The selection of suitable patients is based on an evaluation of level of personality organization and the establishment of a circumscribed treatment focus for each patient, based on his/her patterns of interpersonal problems and main complaints. The article describes how patients are evaluated and prepared, how a treatment culture is developed, phases in the group process and implications for therapist interventions. The article is illustrated with a case history and group material.

Psychodynamic Group Therapy with Hispanic Migrants: Interpersonal, Relational Constructs in Treating Complex Trauma, Dissociation, and Enactments

ABSTRACTThis article introduces an interpersonal, relational approach to group therapy for Hispanic migrants with significant histories of violence, abuse, multiple losses, and recurrent trauma. Psychodynamic group psychotherapy may help to address trauma symptoms, insecure/disorganized attachment, grief, and isolation with newly arrived migrants. How the relational paradigm in group psychotherapy is contributing to current theories of complex trauma and dissociation is reviewed. Using this modality conveys the importance of examining trauma-driven enactments, dissociation and symbolization involving the members of the group, the group-as-a-whole, and the group leader. Clinical examples and group therapy interventions used to address powerful dissociative enactments are discussed.

Cognitive-Behavioral (CBT) and Psychodynamic (PDT) Group Psychotherapy and Their Impact on Depressive Symptoms and Hostile Attributions

ABSTRACTThis article examined how intensive group cognitive-behavioral therapy (GCBT) and group psychodynamic psychotherapy (GPDT) modified depressive symptoms and processing of social information (hostility attributions in a variety of ambiguous situations). The sample (N = 37) comprised individuals who were attending psychotherapy due to psychological distress (GCBT or GPDT). The study examined how group psychotherapy influences depression symptoms and social cognition. There was a decrease in depressive symptoms after three months of intensive CBGT, but PDGT did not significantly improve symptoms of depression. Moreover, in both psychotherapies, the authors noted a significant decrease in hostile attributions, mainly in situations involving people with whom one does not have a close relationship.

The feasibility of a multidisciplinary group therapy clinic for the treatment of nonepileptic seizures

A high percentage of patients presenting to epilepsy centers have a functional neurological disorder with apparent seizures, ultimately diagnosed as nonepileptic seizures (NES). Meta-analyses suggest that psychological treatment is required, but this treatment is not reliably available, resulting in reentry of these patients to neurology clinics and urgent care settings, reducing access for these services to patients with epilepsy and resulting in inadequate psychological care for patients with NES. A sustainable, group therapy-focused treatment clinic for patients with NES was developed as a combined effort between the departments of neurology and psychiatry at the University of Colorado Hospital, consisting of a full psychiatric evaluation, a five-week psychoeducational group, a 12-week psychodynamic therapy group, individual therapy, medication management, and family assessment. One hundred and six patients were treated in this clinic between July 2016 and October 2018. Patient retention after referral for treatment was 89/136 (65.4%), and group therapy adherence was 89/106 (84.0%). Healthcare utilization, used as a proxy to demonstrate worth, decreased during and after treatment. Analysis of the 106 treated patients elucidates other clinical characteristics of this population, including psychiatric comorbidities and specific medication classes at time of NES diagnosis. We conclude that this clinic model is feasible for recruiting, retaining, and engaging patients in appropriate treatment for their NES.

East goes West — West goes East: border crossing and development

In the aftermath of the Nazi era and the Second World War the ‘Bloodlands’ of Eastern Europe including Germany were left with a pervasive and significant loss of empathy. Robi Friedman speaks of the ‘Soldier’s Matrix’ (2015), in which dehumanizing dissociation increases, and empathy, guilt and shame disappear. In the GDR (German Democratic Republic)—under totalitarian and authoritarian conditions—this state of emotional deficit persisted for longer than in the Federal Republic (BRD). Gradually, but only after reunification, could change in the whole of Germany become possible. In the following text I will review the fragmented state of psychoanalysis in the battered city of Berlin after the Second World War. I describe the predicament of psychoanalysts, who are hopelessly entangled in adaptation processes, fearing the new rulers and dreading their own conscience. Despite their weakened sense of courage, they were however able to create space for freedom of thought. I intend to convey the trajectory of that process. The GDR history, despite the experience of confinement, is also a story of opening. Specific developments within the borders enabled the preservation as well as the transportation of psychoanalytic thought: some examples can be seen in inpatient forms of psychotherapy, individual psychodynamic therapy and especially the Intended Dynamic Group Psychotherapy (IDG). The opening of the ‘Wall’ made profound psychoanalytic post-qualification possible, but it came at a cost to the specific developments of the health system in the East. Within this system group therapists took their own particular path. After several years of cautious rapprochement the founding of BIG (Berlin Institute for Group Analysis) could be negotiated and established in 2003, supported by all Institutes of Berlin belonging to the umbrella organization of the DGPT (German Society for Psychoanalyse, Psychotherapy, Psychosomatic). Nine years later the Deutsche Gesellschaft für Gruppenanalyse und Gruppenpsychotherapie (D3G) consolidated in the merger of several individual groups resulting in a continuous and refreshingly pluralistic cooperation today. This article will therefore describe a series of societal shifts, transitions, internal and external attempts to heal, that are well reflected within the parallel process visible in the development of group analysis and its practitioners. One example to consider would be the asymmetry between psychoanalytic ‘teachers’ (West) and ‘students’ (East) and the dynamics experienced during professional encounters, which were very particular and rather complicated. However, that is a chapter in itself and will be considered separately.

Case formulations in mentalization-based group therapy.

Ideally, the assessment phase of patients who are referred to mentalization-based treatment (MBT) should conclude with a mentalization- based case formulation. The structure and content of such case formulations are described. Their aim are: i) to enhance treatment alliance and ii) to provide some structure to the treatment process through suggesting privileged themes related to emotions, relational patterns and mentalizing. MBT is a conjoint kind of psychotherapy, integrating individual and group therapies. Case formulations has belonged to the tradition of individual psychotherapy, while being mostly ignored by group therapists. The question is: are case formulations also relevant for group psychotherapy? How can they be properly introduced while not disturbing the group processes? The theme is discussed through a clinical vignette that illuminates typical therapeutic challenges in dynamic group psychotherapy with borderline patients. The author concludes with some suggestions for clinical structure, process and research.

Značenje simptoma shizofrenog bolesnika tijekom trajanja grupne psihoterapije i nakon njenog završetka

Značenje simptoma shizofrenog bolesnika tijekom trajanja grupne psihoterapije i nakon njenog završetka

A response to ‘A comparative study of a mentalization-based versus a psychodynamic group therapy session’ by Jens Kalleklev and Sigmund Karterud

A response to ‘A comparative study of a mentalization-based versus a psychodynamic group therapy session’ by Jens Kalleklev and Sigmund Karterud

Process-outcome relationships in short- and long-term psychodynamic group psychotherapy: Results from a randomized clinical trial.

Process-outcome relationships in short- and long-term psychodynamic group psychotherapy: Results from a randomized clinical trial.

We Used to Live on Our Own Little Islands: A Qualitative Evaluation of Multifamily Therapy with Veterans

ABSTRACTResearch has shown a consistent negative association between increased symptoms of posttraumatic stress disorder (PTSD) in veterans and successful functioning in family relationships. Despite compelling reasons to involve family members in the treatment of veterans, there is still a significant shortage of evidence-based programs. Multifamily therapy (MFT) is a combination of psychodynamic group therapy with systemic therapy and aims to elicit behavioral changes through the restructuring of interactional patterns in families. The purpose of this study is to qualitatively explore the efficacy of MFT in a convenience sample of Dutch veterans (nine) and their family members (23) who participated in an MFT program. Four basic themes were identified in the transcripts of the semi-structured interviews: 1. stronger family bond and reduced conflict, 2. understanding PTSD and its effect on the family, 3. working with other families, and 4. suggestions for improvement of MFT. In this study, participants described angry outbursts, interpersonal withdrawals, and emotional numbing as characteristic of their daily familial experiences. After MFT, the anger outbursts and fights diminished in most cases. MFT results in more fulfilling relationships within veteran families. MFT does not decrease symptomatology but is capable of enhancing the mental health of the veteran and their family members.

The Iowa Personality Disorder Screen: A validation study in a psychiatric population that receives long-term group psychotherapy for personality related problems.

Personality disorder (PD) is common among psychiatric patients, and diagnosing such disorders is of great importance for the choice of treatment. Diagnosing PD is a demanding and time-consuming process. The utilities of several PD screening instruments have been studied in different populations, but not in a population who receives long-term group psychotherapy. In the current study, we investigate the predictive properties of the Iowa Personality Disorder Screen (IPDS) in a sample of 694 psychiatric outpatients with and without PD who were admitted for psychodynamic long-term group therapy from 2012 to 2014. The definitive, reference diagnoses were defined according to the SCID-II, by which 484 patients (68%) warranted a PD diagnosis. The IPDS correctly classified 67.4 percent of all participants. Sensitivity (0.75) and specificity (0.51) were lower than in previous validation studies of IPDS. We discuss possible explanations related to the general concept of PD and, more specifically, to our study sample. Because of the weaker predictive properties of IPDS, we advise caution in use of the IPDS in similar clinical settings. Copyright © 2018 John Wiley & Sons, Ltd.

A comparative study of a mentalization-based versus a psychodynamic group therapy session

Aims: The purpose of this study was to explore how mentalization-based group therapy (MBT-G) for patients with borderline personality disorder may be both different and similar to a more traditional psychodynamic group psychotherapy approach. Material and methods: The study is a comparative case-study examining a supposedly representative clinical example of MBT-G and a supposedly representative clinical example of a psychodynamic group (PDG). Both groups were composed mainly of patients with borderline personality disorder. The study used a mixed methodological approach with quantitative research methods, including MBT-G Adherence and Quality Scale and Reflective Functioning Scale (RF-scale), and qualitative content analysis. Results: 1) The MBT-G therapists focused consistently on mental states and emotions. This was reflected both in a significantly higher intervention frequency, and in a higher proportion of theoretically assumed mentalizing-promoting interventions. 2) We observed an increase in mentalizing (defined as RF) among some patients in the MBT-G group. In the PDG session, RF development were less systematic, and had lesser impact. 3) Interventions with ‘demand’ characteristics might play an important role in developing a mentalizing group discourse. 4) In both groups, therapists and patients actively structured the sessions, but the MBT-G session more explicitly engaged in ‘meta’ discussions about it, i.e. discussing whether a topic should or should not be put on the agenda. Conclusion: Despite similarities between the approaches, differences in choice of therapeutic focus and consistency suggest that the two methods engage patients in different therapy processes. The results warrant studies that include more sessions in order to validate or falsify the resulting hypotheses.

The effects of short-term group psychodynamic psychotherapy on the personality traits of patients treated in a day ward.

In the literature, there is no research that would indicate how a change in specific personality elements may affect the therapeutic effect of short-term group psychodynamic psychotherapy (STGP). The aim of the study was to evaluate the effect of short-term group psychodynamic psychotherapy on personality traits in apopulation of patients with neurotic and personality disorders in a day ward of neurosis treatment. The study involved 139 people with anxiety and personality disorders, including 110 who participated in the control measurements. The dimensions of personality (neuroticism, extraversion, psychoticism, lie) were assessed on the basis of the Eysenck Personality Questionnaire (EPQ) adapted to the Polish conditions. The measurements were made at two time points: (1) before treatment, (2) after 12 weeks of treatment. During therapy the level of neuroticism, extraversion, psychoticism and lie did not change significantly in the group of neurotic patients. In the group of people with personality disorders, the level of neuroticism significantly decreased (p = 0.0008), whereas the level of extraversion increased (p = 0.037). The values for psychoticism and lie did not change significantly in the course of psychotherapy in any group of patients. The dynamics of changes in neuroticism and extraversion under the influence of short-term group psychodynamic psychotherapy (STGP) in a day ward of neurosis treatment seems to be an important marker for assessing the effectiveness of the treatment in people suffering from personality disorders. There is a need to develop more precise parameters for the assessment of recovery in the group of people with anxiety disorders.

EARLY INTERVENTION PROGRAMME FOR PATIENTS WITH PSYCHOTIC DISORDERS IN “SVETI IVAN”. PSYCHIATRIC HOSPITAL (RIPEPP) - SOCIODEMOGRAPHIC AND BASELINE CHARACTERISTICS OF THE PARTICIPANTS

Psychiatric hospital "Sveti Ivan" in Zagreb, Croatia, offers an outpatient Early intervention programme for patients with psychotic disorders (RIPEPP), consisting of psychoeducational workshops and group psychodynamic psychotherapy. The aim of this study was to describe sociodemographic and baseline characteristics of the participants, in order to provide better understanding of this population, and to assist with the development of more effective therapeutic approaches. Since 2008, a total of 245 patients with first episodes of psychosis and their family members participated in the programme. They filled out several questionnaires within the framework of the programme evaluation, but for the purposes of this study, only data collected on sociodemographic questionnaire and the Health of the Nation Outcome Scales (HoNOS) are presented. Majority of the participants were male (66%), at the average age of 28 (SD=6.6), living with their parents (73.5%). Most of them finished secondary school (45.7%) but almost a quarter of the sample (23.7%) is currently studying at university. The average duration of untreated period was 101.60 days, with a median of 30 days. According to results of HONOS questionnaire, upon entry into the programme, the patients most often listed cognitive functioning (attention, concentration, memory) and professional issues (performance of work tasks and activities tied to work) as the most problematic areas. The findings of this study provide more detailed description of the beneficiaries of the RIPEPP programme, which can contribute to forming future programmes for the prevention of psychotic disorders.

Object relations and self-esteem in young adults with schizophrenia in long-term psychodynamic group psychotherapy

IntroductionPsychodynamic concepts describe object relations deficits in patients with schizophrenia originating from their earliest developmental stage, which is due to reduced ability of direct caregivers to adequately stimulate the child, as well as genetic factors. During psychodynamic group psychotherapy, members through psychotherapy gradually release the old family roles and experiment with new models of behaviour and thus change internalized object representations.AimThe aim of this study was to investigate changes in object relationships and self-esteem in the psychodynamic group psychotherapy in young patients suffering from schizophrenia.Subjects and methodsThe study included a total of 41 patients diagnosed with schizophrenia. Before joining the psychodynamic group therapy and after two years of participation in the treatment, all patients completed a test of object relations and the Rosenberg self-esteem scale.ResultsComparison of the results in two time periods showed downward trend results in all tested dimensions of object relations, a statistically significant difference was found for dimension symbiotic fusion: after two years of participation in the psychodynamic group psychotherapy, patients had significantly expressed less need for symbiotic relationships. Self-esteem was higher in the second period of testing, but without statistical significance.ConclusionTaking into account the limitations of this study, we can conclude that the results are encouraging. During psychodynamic group processes in young patients with schizophrenia there is a trend of positive changes in terms of object relations and self-esteem and a significant reduction in the need for symbiotic merging.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Some stay the same: Personality change after treatment for eating disorder

IntroductionStrong evidence establishes a close relationship between personality traits and mental illness; where personality can be said to influences the likelihood, severity and longevity of a mental disorder. Personality is usually seen as fixed, yet there is a growing body of evidence for the changeability of personality, though this has rarely been studied in relation to mental disorders.ObjectiveTo study the longitudinal interplay between personality and eating disorders (EDs), particularly the associations between personality, recovery and treatment modality.AimsTo investigate changes in the five domains and thirty lower-level facets of personality in non-underweight EDs, and its associations to intervention and outcome.MethodsTwo hundred and nine adults with EDs enrolled either in a four-month multimodal psychodynamic group-therapy (DAY) or four-six month internet-based supported cognitive behavioural therapy (iCBT). ED diagnosis and personality (by the five-factor model) were assessed at baseline, termination and 6-month follow up. Structural equation modeling was used to analyze domain-level development, and reliable change (RCI) for facet-level development.ResultsRemission rate at end of treatment was 71% in DAY and 55% in iCBT. Over time, Neuroticism decreased significantly while Extraversion, Openness and Conscientiousness increased (P < 0.01). Treatment and outcome had little influence on domain-level change. At the facet-level, 28% of patients reliably changed in any given facet, and there were several differences in pattern based on treatment and outcome.ConclusionsThis study lends support for the possibility of personality change and its relevance for recovery from EDs.Disclosure of interestThe authors have not supplied their declaration of competing interest.