Supportive-expressive Psychotherapy Research Articles

Values and Preferences of Patients With Depressive Disorders Regarding Pharmacologic and Nonpharmacologic Treatments : A Rapid Review.

Developers of clinical practice guidelines need to take patient values and preferences into consideration when weighing benefits and harms of treatment options for depressive disorder. To assess patient values and preferences regarding pharmacologic and nonpharmacologic treatments of depressive disorder. MEDLINE (Ovid) and PsycINFO (EBSCO) were searched for eligible studies published from 1 January 2014 to 30 November 2022. Pairs of reviewers independently screened 30% of search results. The remaining 70% of the abstracts were screened by single reviewers; excluded abstracts were checked by a second reviewer. Pairs of reviewers independently screened full texts. One reviewer extracted data and assessed the certainty of evidence, and a second reviewer checked for completeness and accuracy. Two reviewers independently assessed risk of bias. The review included 11 studies: 4 randomized controlled trials, 5 cross-sectional studies, and 2 qualitative studies. In 1 randomized controlled trial, participants reported at the start of therapy that they expected supportive-expressive psychotherapy and antidepressants to yield similar improvements. A cross-sectional study reported that non-Hispanic White participants and men generally preferred antidepressants over talk therapy, whereas Hispanic and non-Hispanic Black participants and women generally did not have a preference. Another cross-sectional study reported that the most important nonserious adverse events for patients treated with antidepressants were insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction. For other comparisons and outcomes, no conclusions could be drawn because of the insufficient certainty of evidence. The main limitation of this review is the low or insufficient certainty of evidence for most outcomes. No evidence was available on second-step depression treatment or differences in values and preferences based on gender, race/ethnicity, age, and depression severity. Low-certainty evidence suggests that there may be some differences in preferences for talk therapy or pharmacologic treatment of depressive disorders based on gender or race/ethnicity. In addition, low-certainty evidence suggests that insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction may be the most important nonserious adverse events for patients treated with antidepressants. Evidence is lacking or insufficient to draw any further conclusions about patients' weighing or valuation of the benefits and harms of depression treatments. American College of Physicians. (PROSPERO: CRD42020212442).

Understanding avoidant attachment in a patient with terminal cancer: a psychoanalytic perspective

Describing the course of a short-term supportive-expressive psychotherapy of a male patient with terminal cancer, this study aimed to illustrate the clinical presentation of avoidant attachment behavior and to identify potential challenges in treating these patients from a psychoanalytic perspective. We analyzed eight therapy sessions, recorded and transcribed as part of a randomized controlled trial, following the explication technique of qualitative content analysis. We analyzed a patient with high attachment avoidance as assessed by the Experiences in Close Relationships Scale measuring adult attachment. We found that ‘attachment avoidance’ subsumed different defense mechanisms, which helped the patient to reduce his fear associated with (1) feelings of dependency: denial, (2) overwhelming distress: isolation of affect, displacement, (3) feelings of guilt and shame: repression, (4) regulating his interpersonal relationships: projective identification. Adding psychoanalytic interpretations to the existing material helped to identify rigid defense mechanisms interfering with sharing his fears about death and dying. Still, the low intensity setting offered him a reliable and tolerable therapeutic relationship. Contributing to the understanding of the specific challenges in treating avoidant patients, our findings underline the importance and feasibility of establishing a holding environment and fostering a positive transference relationship to engage in a joint mourning process.

Management of psychiatric disorders in patients with cancer.

Management of psychiatric disorders in patients with cancer.

The effects of supportive-expressive dynamic psychotherapy on the outcomes of bipolar disorder in men

Background and aims: Bipolar disorder (BD) is a chronic disorder with high recurrence rate and significant disability. BD is refractory to treatments and afflicted patients experience disease recurrence despite medication therapy. Therefore, appropriate psychosocial interventions are needed to improve the effectiveness of medication therapy and facilitate BD management. The aim of this study was to evaluate the effects of supportive-expressive dynamic psychotherapy (SEDP) on the outcomes of BD in men. Methods: This double-blind randomized clinical study was conducted in 2017–2018 using a two-group pretest-posttest design. Participants were thirty hospitalized men with BD conveniently selected from Khorshid hospital, Isfahan, Iran, and randomly assigned to an intervention (n = 15) and a control (n = 15) group. Participants in the control group received conventional medication therapy, while participants in the intervention group received conventional medication therapy as well as SEDP in twelve 60-minute one-to-one sessions. Participants in both groups completed the Bipolar Depression Rating Scale before, immediately after, three months after, and six months after the intervention. The SPSS program for Windows (v. 23.0) was employed to analyze the data via the analysis of covariance and the repeated measures analysis of variance. Results: Although the mean score of bipolar depression significantly decreased at the first posttest, the between-group difference was not significant (P > 0.05). However, the mean score of bipolar depression in the intervention group was significantly less than the control group at the second and the third posttests (P < 0.05). Conclusion: SEDP is effective in significantly reducing mood symptoms among men with BD.

Supportive-Expressive Psychodynamic Psychotherapy for the Treatment of Opioid Use Disorder.

The United States is in the midst of an opioid epidemic with over 200,000 deaths per year due to opioid overdoses. There are numerous psychotherapeutic and medication-assisted approaches to treating opioid use disorder, but psychodynamic approaches remain underappreciated and underused. The self-medication hypothesis of substance use disorders is a psychodynamic model, which argues that all substance use disorders serve to defend against intolerable affects. In the case of opioid use disorders, opioids are thought to help defend against intense intolerable feelings of rage and depression associated with trauma. Supportive-expressive psychodynamic psychotherapy is an empirically supported psychodynamic treatment for a wide range of psychological problems, including opioid use disorders. Supportive-expressive psychodynamic psychotherapy focuses on transference analysis using an operationalized conceptualization of transference called the core conflictual relational theme method. This article describes supportive-expressive psychodynamic psychotherapy for opioid use disorders and provides clinical examples of its use in practice. The article describes and illustrates the three phases of supportive-expressive psychodynamic psychotherapy, the formulation of the core conflictual relationship theme, how it is applied when treating people with an opioid use disorder, and how supportive-expressive psychodynamic psychotherapy can be used with other therapies, such as medication-assisted treatments and 12-step programs. Last, this article encourages psychodynamic therapists who are not involved in treating people with an opioid use disorder to engage in treating people with one using supportive-expressive psychodynamic psychotherapy.

Therapeutic Alliance in COVID-19 Era Remote Psychotherapy Delivered to Physically Ill Patients With Disturbed Body Image.

The COVID-19 pandemic outbreak has led to a general reorganization of health services and an increase in outpatient telemedicine in mental healthcare for physically ill people. Current literature highlights facilitators and obstacles concerning the use of new technologies in psychotherapy, an underrated topic of research in the context of supportive expressive psychotherapy. More insight is needed to explore the characteristics of video in therapeutic alliance for treatment of specific mental disorders experienced in psychosomatics, particularly with people suffering from a disturbed body- and self-image. Using two clinical vignettes, it is the authors’ intention to enrich the critical debate on current knowledge in psychosomatic remote psychotherapy, with special focus on mentalization deficits and their impact on therapeutic alliance in the consultation-liaison psychiatry setting. In particular, we will question the interpersonal processes at stake related to mirroring and the disruption caused by the use of videoconference applications. We will also reflect upon the relationship between the therapeutic alliance and the medical team, and that between patient and psychotherapist. The aim is to improve psychotherapeutic alliance maintained during the pandemic for specific mental disorders and to inform about possible clinical factors that could be the subject of future empirical studies or professional guidelines.

An examination of parent sessions in regulation-focused psychotherapy for children.

Collateral work with parents is a widely adopted practice within child psychotherapy. Therapeutic process within these parent sessions has not been empirically studied or defined, despite a sizable process-outcome literature in both child and adult individual therapy. This link between research and practice is particularly important among manualized, child-focused treatments, where the proposed therapeutic action and clinical approach to parent work is defined according to distinct theoretical principles. To address this gap in the child treatment literature, the present study used the Psychotherapy Process Q Set to examine the in-session processes of parent sessions from 16 treatments of regulation-focused psychotherapy for children (RFP-C). RFP-C is a manualized, psychodynamic treatment for children with disruptive behaviors that consists of 16 child sessions and four collateral parent sessions. The parent-session process ratings were compared to existing adult therapy prototypes and the RFP-C child session prototype. Results indicated that observer-coded psychotherapy process in RFP-C parent sessions was most similar to a cognitive-behavioral therapy prototype and moderately correlated with both a supportive-expressive psychodynamic psychotherapy and a reflective functioning prototype. Observer-coded parent session process was distinct from the RFP-C child prototype. Limitations and directions for future research and clinical practice are discussed. The findings of this study indicate the need to intentionally examine process in parent sessions, both within RFP-C and across modalities, as these sessions have their own unique mechanisms of therapeutic action that ultimately may be additive with regard to child outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Supportive Psychotherapy

Supportive Psychotherapy

Psychosocial Interventions to Promote Recovery for Patient With Schizophrenia: A Systematic Review

Introduction: Managing Cancer and Living Meaningfully (CALM) is a supportive-expressive psychotherapy designed to address such barriers and to facilitate communication of mortality-related concerns in patients facing advanced disease and their primary caregivers. The study was meant to review the benefits of the CALM psychotherapy on patients with advanced or metastatic cancer and caregivers. Methods: This study was done through a systematic review with The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach. It broadly used Scopus, Science Direct, and ProQuest database. The search utilized the Boolean phrases “cancer”, “living meaningfully”, and “psychotherapy” throughout the title, abstract, or keywords. The consideration criteria in the literature study were: an original article, the source from journals, article in English, and available in full text. We obtained 97 articles, and 11 were considered relevant for this systematic review.Results: The findings from the results of this study are that CALM has several psychological benefits for patients with advanced cancer, including: can reduce anxiety and depression, relieve distress, promote psychological growth and well-being, and improve quality of life. Based on these findings, it can be concluded that the CALM psychotherapy has many benefits for patients with advanced cancer and their caregivers and can be used as additional therapy to improve the quality of life to face the end-of-life.Conclusion: CALM may be a feasible intervention to benefit patients with advanced cancer. It may help them overcome obstacles in communication and alleviate death-related distress.

Managing Cancer and Living Meaningfully for Advanced Cancer: A Systematic Review

Introduction: Managing Cancer and Living Meaningfully (CALM) is a supportive-expressive psychotherapy designed to address such barriers and to facilitate communication of mortality-related concerns in patients facing advanced disease and their primary caregivers. The study was meant to review the benefits of the CALM psychotherapy on patients with advanced or metastatic cancer and caregivers.Methods: This study was done through a systematic review with The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach. It broadly used Scopus, Science Direct, and ProQuest database. The search utilized the Boolean phrases “cancer”, “living meaningfully”, and “psychotherapy” throughout the title, abstract, or keywords. The consideration criteria in the literature study were: an original article, the source from journals, article in English, and available in full text. We obtained 97 articles, and 11 were considered relevant for this systematic review.Results: The findings from the results of this study are that CALM has several psychological benefits for patients with advanced cancer, including: can reduce anxiety and depression, relieve distress, promote psychological growth and well-being, and improve quality of life. Based on these findings, it can be concluded that the CALM psychotherapy has many benefits for patients with advanced cancer and their caregivers and can be used as additional therapy to improve the quality of life to face the end-of-life.Conclusion: CALM may be a feasible intervention to benefit patients with advanced cancer. It may help them overcome obstacles in communication and alleviate death-related distress.

Identifying the most suitable treatment for depression based on patients\u2019 attachment: study protocol for a randomized controlled trial of supportive-expressive vs. supportive treatments

BackgroundIn 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.Method/designTo 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).DiscussionThe 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.Trial registrationClinicaltrials.gov Identifier: NCT02728557 submitted on the 15.3.16. Funding: The Israel Science Foundation. Trial status: Recruitment is ongoing.

What is the right time for supportive versus expressive interventions in supervision? An illustration based on a clinical mistake.

Although supportive-expressive (SE) psychotherapy is one of the most studied psychodynamic therapies today, little is known empirically about effective strategies in SE supervision, or in psychodynamic supervision in general (Diener & Mesrie, 2015; Watkins, 2011). One of the important questions in SE psychotherapy is how to decide when to use supportive and when to use expressive interventions. As a parallel process, this type of decision is relevant also to SE supervision. The present case study focuses on the decision-making process in an SE supervision session: when should supervisors use supportive as opposed to expressive strategies with their supervisees? Our aim is to develop decision rules that reliably support supervisors' decisions. We analyze a clinical error made by supervisors in this type of decision making, and show how mistakes of this type can either be avoided or, when they occur, how to turn them into opportunities for learning and for the formation of new understanding and growth. Similarly to the finding that therapists with better skills in managing their countertransference feelings were shown to have better outcomes with their patients (Gelso, Latts, Gomez, & Fassinger, 2002; Hayes, Gelso, & Hummel, 2011), we suggest that the management of the supervisors' feelings, and working through their mistakes with the therapists, can contribute to the supervisory relationship and to the development of the psychodynamic therapists' skills. (PsycINFO Database Record

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

BackgroundThe goal of the study was to examine two central theory-driven mechanisms of change, causal attributions and relational representations, to account for symptomatic improvement in psychodynamic treatment and supportive clinical management, combined with either pharmacotherapy or placebo, in a randomized control trial (RCT) for depression. MethodWe used data from an RCT for depression, which reported non-significant differences in outcome among patients (N=149) who received supportive-expressive psychotherapy (SET), clinical management combined with pharmacotherapy (CM+MED), or clinical management with placebo pill (CM+PBO) (Barber et al., 2012). Mechanism and outcome measures were administered at intake, mid-treatment, end of treatment, and at a 4-month follow-up. ResultsImprovements in causal attributions and in relational representations were found across treatments. Changes in causal attributions did not predict subsequent symptomatic level when controlling for prior symptomatic level. In contrast, decrease in negative relational representations predicted subsequent symptom reduction across all treatments, and increase in positive relational representations predicted subsequent symptom reduction only in SET. LimitationsThe study is limited by its moderate sample size. Additional studies are needed to examine the same questions using additional treatment orientations, such as cognitive treatments. ConclusionsFindings demonstrate that changes in negative relational representations may act as a common mechanism of change and precede symptom reduction across psychodynamic therapy and supportive case management combined with either pharmacotherapy or placebo, whereas an increase in positive relational representation may be a mechanism of change specific to psychodynamic therapy.

Therapist-reported alliance: Is it really a predictor of outcome?

Most of the literature on the alliance-outcome association is based exclusively on differences between patient reports on alliance. Much less is known about the unique contribution of the therapist's report to this association across treatment, that is, the association between therapist-reported alliance and outcome over the course of treatment, after controlling for the patient's contribution. The present study is the first to examine the unique contribution of the therapist-reported alliance to outcome, accounting for reverse causation (symptomatic levels predicting alliance), at several time points in the course of treatment. Of 156 patients randomized to dynamic supportive-expressive psychotherapy, antidepressant medication with clinical management, and placebo with clinical management, 149 were included in the present study. Alliance was assessed from the perspective of both the patient and the therapist. Outcome measures included the patients' self-reported and diagnostician-rated depressive symptoms. Overall, the findings demonstrate that the therapists' contribution to the alliance-outcome association was explained mainly by prior symptomatic levels. However, when a time lag of several sessions was introduced between alliance and symptoms, a positive association emerged between alliance at 1 time point and symptomatic distress assessed several sessions later in the treatment, controlling for previous symptomatic level. The findings were similar whether or not we controlled for the patient's perspective on the alliance. Taken together, the findings attest to the importance of improving therapists' ability to detect deterioration in the alliance.

Does psychodynamic short-term psychotherapy for depressed breast cancer patients also improve fatigue? Results from a randomized controlled trial.

The purpose of this study was to determine (a) the course of fatigue in depressed breast cancer patients, (b) the effect of a depression-focused individual psychodynamic psychotherapy on fatigue, and (c) the associations of fatigue with depression, quality of life and treatment-related variables. In a German multicentre randomized controlled trial in Leipzig and Mainz, depressed early breast cancer patients (UICC stage 0-III, age 18-70 years) were randomly assigned to a short-term psychodynamic psychotherapy (STPP, an adaptation of the Supportive-Expressive psychotherapy by Luborsky for cancer patients) or treatment as usual (TAU) and completed data assessment pre- and post-treatment. Fatigue was assessed with the Multidimensional Fatigue Inventory (MFI-20). All analyses were conducted as complete case analyses including 52 STPP and 54 TAU completers (n = 106). The trial is registered at http://www.controlled-trials.com , number ISRCTN96793588. Fatigue declined significantly from a high level pre-treatment to post-treatment, but remained significantly higher than among population-based controls and a mixed sample of cancer patients. Significant time by group interactions favoured STPP for the subscales reduced activity and physical fatigue and the total scale. The strength of the associations between total fatigue and depression increased from 0.49 pre-treatment to 0.63 (Quality of life -0.52 to -0.63) at follow-up. STPP is beneficial for reducing dimensions of fatigue (particularly reduced activity and physical fatigue) in depressed breast cancer patients. Chronic fatigue needs more clinical attention in this vulnerable group.

Goldilocks on the couch: Moderate levels of psychodynamic and process-experiential technique predict outcome in psychodynamic therapy

Objectives: Greater symptom change is often assumed to follow greater technique use, a “more is better” approach. We tested whether psychodynamic techniques, as well as common factors and techniques from other orientations, had a curvilinear relation to outcome (i.e., whether moderate or “just right” intervention levels predict better outcome than lower or higher levels). Methods: For 33 patients receiving supportive-expressive psychodynamic psychotherapy for depression, interventions were assessed at Week 4 using the multitheoretical list of therapeutic interventions and symptoms were rated with the Hamilton Rating Scale for Depression. Results: Moderate psychodynamic and experiential techniques predicted greater symptom change compared to lower or higher levels. Conclusion: This “Goldilocks effect” suggests a more complex relation of intervention use to outcome might exist.

The associations among improvement and alliance expectations, alliance during treatment, and treatment outcome for major depressive disorder

Objective: To examine the associations between treatment/outcome expectations, alliance before and during treatment, and the impact of alliance on symptomatic improvement. Methods: One hundred and fifty-three depressed patients randomized to dynamic supportive-expressive psychotherapy (SET), antidepressant medication (ADM) or placebo (PBO) + clinical management completed ratings of treatment expectations, therapeutic alliance (CALPAS, WAI-S), and depressive symptoms (HAM-D). Results: Pretreatment expectations of the therapeutic alliance were significantly related to alliance later in therapy but did not differ across treatments and did not predict outcome. Alliance development over time differed between treatments; it increased more in SET than in PBO. After controlling for prior symptom improvement, early alliance predicted subsequent depression change. Conclusions: Expectations of alliance and of treatment outcome/improvement, measured prior to treatment onset, predicted subsequent alliance.

Does alliance predict symptoms throughout treatment, or is it the other way around?

Scholars increasingly recognize that therapeutic alliance and symptomatic change are associated with one another. A common assumption is that alliance predicts symptomatic change. However, the issue is far from settled. One challenge in determining the causality is the establishment of temporal precedence showing that alliance, as opposed to previous symptomatic change, drives subsequent symptomatic reduction. To make further advances in untangling this chicken-and-egg question, we employed autoregressive cross-lagged modeling over 4 time points in a sample of 149 depressive patients receiving supportive-expressive psychotherapy or clinical management combined with pharmacotherapy or clinical management combined with placebo. Using this methodology, we found that both alliance and symptoms across treatment made significant and unique contributions in predicting subsequent symptomatic levels throughout treatment. Additionally, alliance, but not symptoms, predicted subsequent alliance levels. No differences were found between treatments. Our findings imply that alliance temporally precedes symptomatic levels throughout treatment.

Pragmatic Psychodynamic Psychotherapy—Bridging Contemporary Psychoanalytic Clinical Practice and Evidence-Based Psychodynamic Practice

Pragmatic psychodynamic psychotherapy (PPP; Summers & Barber, 2009) describes the therapeutic principles and approaches found in many forms of manualized psychodynamic psychotherapies, which are being used in research studies with the aim of building an evidence-based psychodynamic practice. This article focuses on one such treatment, Supportive-expressive psychotherapy (SEP; Luborsky 1984), which employs the Core Conflictual Relationship Theme (CCRT) method to formulate core interpersonal problems and treatment goals and identify therapeutic interventions. To illustrate SEP, we describe the 40-session treatment of a patient who met diagnostic criteria for several personality disorders. The case illustrates how complex ego-syntonic character pathology is expressed in CCRT terms and worked through in the transference, gradually becoming ego-dystonic and amenable to modification. In this case, the patient became more aware of his interpersonal wishes and vulnerability. Although his anxiety increased somewhat, he had an improvement in psychosocial functioning.

Interpersonal problems as predictors of alliance, symptomatic improvement and premature termination in treatment of depression

BackgroundPrevious studies reported inconsistent findings regarding the association of interpersonal problems with therapy outcome. The current study investigates if interpersonal problems predict process and outcome of three different treatments for depression. MethodsThe data originate from a randomized clinical trial comparing supportive–expressive psychotherapy, antidepressant medication and pill-placebo for treatment of depression. Interpersonal problems were used as predictors of alliance, symptomatic improvement and premature termination of treatment. ResultsInterpersonal problems related to communion predicted better alliances, but slower symptomatic improvement. Low agency predicted slower symptomatic improvement in supportive–expressive psychotherapy, but not in the medication or placebo condition. Lower interpersonal distress was associated with an increased likelihood to terminate treatment prematurely. LimitationsThe sample size did not allow the detection of small effects within the treatment groups. ConclusionsInterpersonal problems are influential for the treatment of depression, but parts of their effects depend on the type of treatment.