Transference-Focused Psychotherapy for Borderline Adolescents: A Neurobiologically Informed Psychodynamic Psychotherapy

In this article we first contextualize and then outline a model of TFP adapted for working with adolescents with Borderline Personality Disorders. We discuss how to take the normal developmental challenges of adolescence, such as separation-individuation in consideration, and how to support this in the context of the therapeutic work, while at the same time stimulating curiosity through clarification and confronting the adolescent with self-defeating and destructive patterns and dangerous behavior. Furthermore, we give examples of working with split–off parts of self and other representations through clarification to increase self-awareness and confrontations with contradictions within the adolescents communication and nonverbal behavior, with the aim of facilitating the integration of identity.     

Therapy Expectations of Adolescents with Depression Entering Psychodynamic Psychotherapy: A Qualitative Study

Patient expectations about therapy have been regarded as a common factor affecting the course and outcome of psychotherapy. However, little is known about the expectations of adolescents. We aimed to explore the therapy expectations of young people (YP) with depression prior to psychotherapy. We conducted semi-structured interviews with six YP (5 female, 15–19 years old) entering psychodynamic outpatient treatment. Interviews were transcribed verbatim and analyzed using Interpretative Phenomenological Analysis. The careful analysis of the YPs’ accounts yielded the following four key themes: not knowing but being cautiously hopeful; therapy as a long and difficult process; therapy as a place to understand oneself and to develop; and the importance of the professional and interpersonal skills of the therapist. The findings suggest to foster realistic treatment and outcome expectations while at the same time individual therapists should pay careful attention to the specific expectations that YP bring into therapy.     

The Development and Role of the Therapeutic Alliance in Supportive Psychotherapy with Adolescents

The formation of a therapeutic alliance is considered a central issue in therapy, and particularly crucial and challenging in work with adolescents. The relational and technical components of the therapeutic alliance were examined from the perspective of the adolescent client. 40 emotionally disturbed adolescent girls, aged 13 to 16 years, received brief supportive psychotherapy in the school setting. The alliance was assessed at sessions 3, 6 and 9, and outcome was evaluated on measures of internalizing problems, self-esteem, adjustment and client satisfaction. The results indicated the stability of the alliance between sessions 3 and 6, followed by significant linear increases between sessions 6 and 9. The strength of the alliance was most consistently related to reductions in internalising problems and client estimates of change. The implications for training and clinical practice with adolescent clients are discussed and future research avenues outlined.     

Conceptualizing Psychopathy: A Psychodynamic Approach

Drawing from analytic theory and clinical conceptualization, three major types of psychopathy are detailed: Superego deficit, aggression driven, and sadism. The types of psychopathy are discussed in terms of their overlap with personality disorders. The range of sadism is charted from the enjoyment of inflicting pleasure to the borderline manifestations in compulsive reenactments in psychopathic patients. Two categories of antisocial behavior— low social intelligence and poor impulse control—are elaborated clinically as inconsistent with the psychodynamic formulation of characterological psychopathy. The divergence between psychodynamic and behavioral approaches to antisocial behavior is discussed, and unresolved enigmas in the formulation of psychopathy are outlined.     

Prevention of Initial Depressive Disorders Among at-Risk Portuguese Adolescents

This study evaluated whether Arnarson and Craighead’s (2009, 2011) developmentally based behavioral and cognitive program that prevented the initial episode of depressive disorders among Icelandic adolescents could be adapted to prevent depressive disorders among “at-risk” Portuguese adolescents. One hundred sixty-eight Portuguese mid-adolescents (primarily 14 to 15 years old), who had subsyndromal symptoms of depression but who had never met criteria for a depressive disorder, were identified by classroom screening with the CDI and subsequent K-SADS-PL interview. All 168 adolescents were offered participation in the 14-week prevention program; 70 agreed to participate in the program, and 98 agreed to participate only in an assessment control group. Psychological disorders were evaluated at baseline, 6-, 12-, 18-, and 24-month assessments. During the 2-year follow-up period, 12 students in the assessment-only group experienced an initial depressive disorder versus 2 in the prevention group. Survival analyses indicated a significantly lower rate of initial episodes of depressive disorders, χ²(1) = 4.261, p = .039, among the prevention group participants compared to the assessment only comparison group. The hazard ratio was .207, and the NNT was 11. Survival analyses indicated no significant differences between the prevention condition and the assessment only condition in the occurrence of other psychiatric disorders, χ2(1) = 1.080, p = .299. The findings indicate the program can be successfully adapted for use in Portuguese schools, and they provide a preliminary indication that those “at-risk” adolescents who chose to participate in the program, compared to those who chose to participate only in the assessments, developed fewer initial episodes of depressive disorders over the course of 24 months. The program effects were similar to the outcomes of the prior study of this program in Iceland. As in the Icelandic version of the program, its effects appeared to be specific to the depressive disorders for which the program was designed.     

Short-Term Psychoanalytic Supportive Psychotherapy for Depressed Patients

Short-Term Psychoanalytic Supportive Psychotherapy (SPSP) is a face-to-face, individual psychotherapy, consisting of sixteen sessions in six months (first eight weekly, then eight fortnightly sessions). It is rooted in psychoanalytic theory. Its primary aim is to cure depression. A secondary goal is to reduce a patient's vulnerability to depression. The emphasis is on supportive techniques that counter regression and foster psychological growth. The putative process consists in experiencing a relational dissonance, i.e., feeling two contradictory relationships in the therapeutic situation simultaneously, one determined by the past, the other by the present. We assume an important curative factor is to experience, mostly unconsciously, an adequate gratification of developmental needs inadequately met in early infancy and, therefore, manifesting themselves in the archaic aspects of the therapeutic relationship. SPSP unfolds as a discourse in which we distinguish nine levels. Each regards a specific subject, which at that level is the focus of the interaction between patient and therapist. The efficacy of SPSP in ambulatory patients presenting a DSM-IV defined, mild to moderate major depressive disorder has been tested in five randomized clinical trials. The results have been aggregated in a mega-analysis. They suggest that, in the treatment of outpatients with mild to moderate major depressive disorder, SPSP and pharmacotherapy are equally efficacious and that the combination of SPSP and pharmacotherapy is more efficacious than pharmacotherapy alone but not than SPSP alone. We, therefore, consider SPSP a valuable extension to the existing options for the treatment of depressed patients.     

A Psychodynamic Treatment for Severe Personality Disorders: Issues in Treatment Development

We describe a psychodynamic treatment modified for patients with severe personality disorders identified as borderline personality disorder in DSM-IV, Axis II, and understood as borderline personality organization from a psychoanalytic perspective. This treatment is labeled transference-focused psychotherapy (TFP) in order to highlight the centrality of working with these patients in the here-and-now treatment interaction. The empirical development of TFP is described, including the generation of a treatment manual, the utility of various methods to teach the treatment, and preliminary data on efficacy. The latest step in the development of this treatment is an ongoing randomized clinical trial comparing the efficacy of TFP to a cognitive-behavioral and a supportive treatment.     

Psychotherapy for Individuals with Autism Spectrum Disorders

Individuals with autism spectrum disorders (ASDs) present unique challenges for psychotherapists. Those with autism, Asperger’s Disorder and pervasive developmental disorder-not otherwise specified (PDD-NOS) show impairments in social communication and social relationships as well as unusual behavioral features that set them apart from peers. Further, individuals affected with autism spectrum disorders may experience anxiety, depression, obsessive–compulsive disorder and other psychiatric symptoms that can be distressing and, at times, disabling. At present, there is limited information regarding evidence-based approaches for addressing either core impairments of ASDs or associated conditions in a psychotherapy setting. Nevertheless, information about how persons with ASD experience their world and learn can provide clues about what interventions might be useful to assist them such that they can reach their fullest potential. From this standpoint, new or modified approaches to therapy can be tested and further refined to provide a more comprehensive understanding of the psychotherapeutic challenges and the most efficacious therapeutic approach to maximize functioning in this population.     

Cognitive-Behavioral Versus Supportive Psychotherapy for Intermittent Explosive Disorder: A Randomized Controlled Trial

Few clinical trials have evaluated the efficacy of psychotherapy for Intermittent Explosive Disorder (IED). The present study tested the efficacy of a cognitive behavioral intervention (versus supportive psychotherapy) among adults with IED. In this randomized clinical trial, 44 participants with IED (22 men and 22 women) aged 20–55 years completed twelve 50-minute individual sessions of either a multi-component cognitive behavioral intervention for IED (n = 19) or a time equated supportive psychotherapy (n = 25). At baseline, posttreatment, and 3-month follow-up, all participants received the Overt Aggression Scale–Modified, which was conducted by an interviewer who was blind to the participant’s study condition. During these visits, participants also completed self-report measures of relational aggression (Self-Report of Relational Aggression and Social Behavior), anger (State-Trait Anger Expression Inventory-2), cognitive biases (e.g., Social Information Processing Questionnaire Attribution and Emotional Response Questionnaire), and associated symptoms (e.g., Beck Depression Inventory). Primary study outcomes were aggressive behavior and anger. Though participants in both treatments tended to improve over time, the cognitive behavioral intervention was superior to supportive psychotherapy in decreasing aggressive behavior and relational aggression. These findings support the efficacy of a multicomponent cognitive behavioral intervention in treating aggression in IED.     

Mordechai Rotenberg's Dia-logo Therapy: A New Approach to Dialogical Psychotherapy

This article attempts an overview of Mordechai Rotenberg's second and third books, Dialogue with Deviance and Re-Biographing and Deviance, and an in-depth analysis of his fourth book Dia-logo Therapy. It shows how Rotenberg builds on his early studies of Protestantism and American individualism and on his Talmudic, Hasidic, and Jewish hermeneutic background to offer a challenging rereading of the task of the therapist. This includes the bridging of the rational and the irrational, the factual and the mystical, through psychonarration and re-biographing. It also includes a trenchant distinction between the unilateral truth of Aristotle, Hegel, Marx, and Freud and the multilateral truth of Socrates, the Talmud, and Martin Buber. Throughout the article a comparison is made between Rotenberg's thought and that of both Martin Buber and Maurice Friedman.     

Adolescent Focused Psychotherapy for Adolescents with Anorexia Nervosa

The paper describes a manualized specific form on individually based developmentally oriented therapy for Anorexia Nervosa (AN) in adolescents. Adolescent focused psychotherapy for AN is derived from a self-psychology model and is designed to address key deficits in development associated with AN. Adolescents with AN are viewed as using food and weight to avoid negative affective states associated with adolescent developmental issues that they perceive as intolerable. To develop a more constructive coping style and improve self-efficacy, adolescent patients need to first learn to identify and define their emotions, and later, to tolerate emotions, particularly negative ones. In withdrawing from the environment and situations which provoke distress through self-starvation and preoccupations with food and weight, emotional and psychological development is arrested. Learning to identify and cope adaptively with emotions and developmental challenges presented by the environment form the key therapeutic targets of treatment. Specific therapeutic procedures, a case illustration and discussion of therapeutic rationale are also provided.     

Using Rebt and Supportive Psychotherapy with Post-Stroke Patients

This paper discusses the benefits of using Calabro's (1990) three-stage cognitive-behavioral model, to determine when to use supportive Psychotherapy or Rational-Emotive Behavior Therapy (REBT) with post-stroke patients. It also discusses the benefits of using a support group and how to decide when to use a group and/or individual psychotherapy.     

Anxiety Disorders in Children and Adolescents with Autistic Spectrum Disorders: A Meta-Analysis

There is considerable evidence that children and adolescents with autistic spectrum disorders (ASD) are at increased risk of anxiety and anxiety disorders. However, it is less clear which of the specific DSM-IV anxiety disorders occur most in this population. The present study used meta-analytic techniques to help clarify this issue. A systematic review of the literature identified 31 studies involving 2,121 young people (aged <18 years) with ASD, and where the presence of anxiety disorder was assessed using standardized questionnaires or diagnostic interviews. Across studies, 39.6% of young people with ASD had at least one comorbid DSM-IV anxiety disorder, the most frequent being specific phobia (29.8%) followed by OCD (17.4%) and social anxiety disorder (16.6%). Associations were found between the specific anxiety disorders and ASD subtype, age, IQ, and assessment method (questionnaire versus interview). Implications for the identification and treatment of anxiety in young people with ASD are discussed.     

Group Psychotherapy: A Behavioral Approach

Abstract

This clinical report highlights some of the processes arising in a therapy group of persons with persistent and chronic psychiatric illnesses as they cope with the stress of their long–standing therapist’s impending retirement. Members were initially disbelieving that the therapist would leave and were also concerned about their future care, particularly in terms of medications. Gradually they were more able to experience their feelings of loss and their genuine caring for the therapist and the group, using higher level defenses and increasing their ability to tolerate strong affects. They became increasingly able to demonstrate empathy, notably in their ability to consider the therapist’s emotions. The clinical material also illustrates the therapist’s personal involvement, countertransferences and expressions of concern.     

Early Adversity and the Prospective Prediction of Depressive and Anxiety Disorders in Adolescents

The current study was a prospective exploration of the specificity of early childhood adversities as predictors of anxiety and depressive disorders in adolescents. Participants were 816 adolescents (414~males, 402 females) with diagnostic information collected at age 15; information on early adversities had been collected from the mothers during pregnancy, at birth, age 6 months, and age 5~years for a related study. Adolescents with pure anxiety disorders were compared with adolescents with pure depressive disorders (major depressive disorder, dysthymia), and these groups were compared to never-ill controls. Analyses controlled for gender and maternal depression and anxiety disorders. Results indicated that adolescents with anxiety disorders were more likely than depressed youth to have been exposed to various early stressors, such as maternal prenatal stress, multiple maternal partner changes, and more total adversities, whereas few early childhood variables predicted depressive disorders. Even when current family stressors at age 15 were controlled, early adversity variables again significantly predicted anxiety disorders. Results suggest that anxiety disorders may be more strongly related to early stress exposure, while depressive disorders may be related to more proximal stressors or to early stressors not assessed in the current study.