Countertransference feelings in the treatment of borderline patients (PhD-projekt)
The project investigates in at quantitative study (N=42) the relation between countertransference feelings and certain characteristics of borderline patients within data obtained by SCL-90-R, IIP, DSQ-40, SIIP-118 and SCID-II. The psychotherapists countertransference feelings is obtained by Feeling Word Checklist, FWC-58.
In a qualitative study two patients is included for psychoanalytic psychotherapy and a case study is made of session notes. This study makes the basis for discussing the concept of countertransference and to discuss and compare the results of the qualitative study in a more methodological discussion of the science of psychoanalysis.
69 patients ›18 years of age with a diagnosis of BN, i.e. fulfilling the DSM-IV criteria.
The patients are randomly assigned to one of two treatments:
Adult Attachment Interviews (AAI) are administered to everyone at intake, after 6 months and after 24 months and the approx. 190 AAI’s will subsequently be rated by reliable coders for RF using the RF Scale with scores ranging from -1 to 9.
EDE and SCID-II (Spitzer et al., 1990) data is also available for all patients at the same intervals and will be used in the subsequent analysis. A normal control group of 20 individuals matched for age and educational level were also interviewed with AAI and subsequently rated for RF.
At the present moment 135 AAI’s have been coded for RF. A pilot reliability test (n=20) show promising results with an interrater reliability of 0.91. Data analysis will be completed 2011.
Formålet med undersøgelsen er at sammenligne såvel den umiddelbare effekt som langtidseffekten af to forskellige former for individuel psykoterapi ved bulimi, kognitiv adfærdsterapi (KAT) i 20 uger og psykoanalytisk psykoterapi (PPT) i 2 år.
I overensstemmelse med Agras et al. (2002) er de primære effektvariable følgende:
Alder: ³ 18 år.
Patienter opfylder DSM-VI’s kriterier for bulimia nervosa.
Patienten har læst informationsskrivelsen til patienter samt underskrevet samtykkeerklæring.
Samtidig ICD-10 diagnose indenfor kategorierne F00-31 (organiske lidelser, misbrugsrelaterede lidelser, lidelser indenfor det skizofrene spektrum, maniske eller bipolære lidelser), F32.1, 32.2, 32.3, 33.1, 33.2 and 33.3 (moderat til svær depression).
Samtidig ICD-10 diagnose indenfor kategorierne F40-49 (angstlidelser, disociative lidelser, somatoforme lidelser), hvis den pågældende lidelse vurderes på afgørende vis at besværliggøre eller forhindre den psykoterapeutiske behandling af bulimi.
Alkoholafhængighed eller misbrug af psykoaktive stoffer.
Samtidig somatisk sygdom som på afgørende vis vil besværliggøre eller forhindre den psykoterapeutiske behandling.
Graviditet eller planer som interfererer med behandlingen såsom længere udenlandsrejser.
Vanskeligheder med at tale og/eller forstå dansk.
Bulimidiagnosen stilles udfra Eating Disorder Examination (EDE) (Fairburn & Cooper, 1993), et semi-struktureret interview udviklet til DSM-IV diagnosticering af spiseforstyrrelser og til vurdering af behandlingseffekt.
Herudover vil patienterne blive interviewet udfra: a) Present State Examination - Kort version til klinisk brug (PSE) (Bertelsen, 1995) med henblik på at identificere mulige eksklusionskriterier, b) Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) (Spitzer et al., 1990) for at diagnosticere eventuelle personlighedsforstyrrelser, og c) Karolinska Psychodynamic Profile (KAPP) (Weinryb & Rössel, 1991).
Cutting-phenomena in borderline patients is connected to a concept of “non-representation” – which also manifest itself empirically in chronic feelings of emptiness, in feelings of deficiency and in forms of acting-out phenomena
Aim of the project
To create a psychoanalytic understanding of cutting in relation to borderline
To create a psychoanalytic understanding of the experiences of chronic emptiness that many borderline patients is plagued by
How is borderline personality disorder related to cutting?
How to understand emptiness – phenomenological and theoretically?
What is the meaning of the skin in the self destructive act?
Design and Method
A. Semi-structured interviews
Population: Approx. 40 patients
Frequency: 1 interview
Duration: Aprox. 1 hour
To explore the relationship between cutting and psychic-representation.
To expand the understanding of deficiency in relation to cutting
To create a method of conceptualising non-representational psychic material
Data: Phenomenological descriptions and categorizations of qualitative markers
Method: Audio recordings; transcriptions or listening for joint patterns of pathology with an interrater.
B. Single-case studies
Population: 3 borderline patients who self-harm by cutting
Frequency: Twice weekly for 18 months
Duration: 45 minutes
Purpose: To treat the patients
To expand the understanding of self-harm in relation to psychic representation
To deduce procedural conditions concerning non-representation
Material due to the transference or “betweenity” (Gammelgaard, 2004)
Process notes and supervision
The project receives data from Susanne Lunns and Stig Poulsens randomised controlled trial of psychotherapy for Bulimia Nervosa (see above). 69 women and one man aged 19-42 fulfilling DSM IV criteria for bulimia nervosa (BN), assessed on the Eating disorder Examination (EDE) interview, were interviewed with the Adult Attachment Interview (AAI), which was subsequently coded for Reflective Functioning (RF). Furthermore patients were interviewed with SCID-II too determine the prevalence of personality disorders. Finally participants filled in a questionnaire on autobiographic information. Twenty expectant mothers matched to the patient group on educational level and age, originally interviewed with the AAI in 2001-2002 as part of a study on transgenerational transmission of attachment, served as a normal comparison group.
On average, the sample of patients suffering from BN seems to have close to normal mentalizing abilities. However, the distribution of RF scores was significantly different from the distribution of RF in the normal control group. BN subjects showed a more polarized pattern with more low and high RF scores, while control subjects mainly received RF scores in the moderate range. The study found no differences in the mentalizing abilities of bulimic patients with and without a co-morbid BPD.
The mirror project is based on the development of the mirror interview, which aims to understand ways in which adolescents with personality disorder see and understand themselves in contrast to how adolescents in a control group see and understand themselves.
The sense of self is often thought of as an individual, psychological entity. The mirror interview is useful in examining other important aspects of the sense of self in particular the role of the body and the contribution of a third person perspective on the sense of self.
The mirror interview can reflect pathological processes in the understanding of self, which are difficult to capture in more traditional style interviews. In the mirror interview, the sense of self as imagined by others seems to be an important component of the sense of self.
The sense of self is affected in a variety of ways and degrees in most if not all forms of psychiatric disturbance. The mirror interview underlines an important aspect of self understanding; the way in which the subject imagines that other people see him or her
During the mirror interview the subject looks at the self whilst answering questions posed by the interviewer. In this way the subject is confronted by a subjective sense of self at the same time as seeing the self from an observer’s position.
This is done in the presence of a third person, the interviewer.
65 adolescents between the ages of 12 and 21 in a control group were compared with 65 adolescents with a personality disorder.
To ascertain the presence of a personality disorder the adolescents were given a structured interview SCID –II.
In addition all subjects were interviewed with the Adult Attachment Interview and several rating scales were completed, The Identity Consolidation Inventory, The Child Behaviour Checklist, Defense Style Questionnaire.
A mirror rating instrument was designed and Inter Rater Reliability is being tested.
Psychodynamic Psychotherapy vs Treatment as Usual for psychosis: A comparative, prospective, longitudinal study of first-episode schizophrenia
The study was designed as a prospective, comparative, longitudinal multi-site investigation of consecutively referred patients who were included during two years (1997-1999). The patients were treated with either manualised individual supportive psychodynamic psychotherapy (SPP) in addition to treatment as usual or with treatment as usual alone (TaU). Symptoms and functional outcomes were measured using the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale (GAF). Oher data was gathered at inclusion, year 2 and 5, including: demographic data, Strauss-Carpenter Scale, OPCRIT, Rorschach a.m. Exner, Selected variables of WAIS.
The manual for the Supportive Psychodynamic Psychotherapy is available by request.
Results after two years: 269 patients, age 18-35, were included of whom 79% remained in the study after two years. The intervention group improved significantly on measures of both PANSS and GAF scores, with large effect sizes at two years follow-up after inclusion. Furthermore, improvement on GAFfunction (p=0.000) and GAFsymptom (p=0.010) significantly favoured SPP in combination with TaU over TaU alone. Other dimensions improved during the two years but not statistically significant.
Publication of 5 years data are in preparation, and it seems as if the GAF(function) improves significantly in favour of the Supportive Psychodynamic Psychotherapy
Publication of Rorschach data are in preparation
The research is focussed on developing, analyzing, and evaluating different forms of interventions directed towards the field of child sexual abuse and trauma from a French psychoanalytic perspective. The intervention forms are established on the basis of development of theory, clinical and therapeutic work, empirical studies, as well as an ongoing involvement and interaction with the broad field of child sexual abuse and trauma with the many different fields of praxis that are involved in this area. The intervention forms are directed towards academic, clinical, educational, social, and political areas related to the work of child sexual abuse.
Centre of Psychoanalysis has been founded in 2010 to establish an academic point of departure for the working with psychoanalytic theory and praxis, thus letting Academic Psychoanalysis in Denmark partake in the international sharing and developing of academic psychoanalysis with its base in The Department of Psychology. In this setting my research is focussed primarily on the development of psychoanalytical theory and clinical practice in relation to the field of infantile sexuality and sexual trauma in cooperation with Judy Gammelgaard as well as on the analysis of the relation between psychoanalysis and empirical research in cooperation with Judy Gammelgaard and Signe Holm Pedersen.
At present I am leading the research group: ”Trauma and development”. The present aim of the group is the development, empirical testing and evaluation of educational material directed to children age 3-14 years old. The educational material is founded on French psychoanalytical theory and has as its goal to educate professionals to strengthen children’s understanding of boundaries, empathy and sexuality. The educational material will be distributed on a national basis to public institutions working with children that have been or are at risk of being abused sexually. Parallel with this the research group is working on reviews on prevention of child sexual abuse as well as on suspicions of child sexual abuse.
"Det psykoterapeutiske evalueringsprojekt på afdeling E12", psykoterapeutiske ambulatorium, Bispebjerg Hospital, er en åben naturalistisk undersøgelse, der siden sin start i 1990 og indtil afslutningen i 2003, inkluderer 1268 patienter. Mere end 90% af samtlige adspurgte patienter har ønsket at deltage i projektet. Den hyppigste behandlingsform er et 3 måneders gruppe-terapeutisk tilbud, fordelt på ialt på 39 sessioner af hver 2 timers varighed, evt. suppleret med tegne-terapi, kropsterapi, eller motion. Disse grupper er overvejende for patienter med sværere neurotiske forstyrrelser i form af angsttilstande og depressive reaktioner. Desuden er der særlige behandlingstilbud på afdelingen for incest, bulimi/anorexi, samt for patienter med grænsetilstande.
Undersøgelsen er prospektiv med før, efter og 1.års follow-up data. Psykiatriske og demografiske variable registreres ved visitations-interviewet, herunder vurdering af funktionsniveau. De prospektive mål inkluderer Symptom Check List 90-Revised (SCL-90-R), Millon Clinical Multiaxial Inventory II (MCMI II), samt visuelle analog skaler vedrørende aktuelt befindende og psykodynamisk fokus. Ved afslutningen af terapien vurderer såvel patienter som terapeuter retrospektivt udbyttet af behandlingen i 15 relevante domæner, samt eventuelt behov for yderligere foranstaltninger. Ved follow-up besvarer patienten SCL-90-R, MCMI, samt aktuel psykologisk og arbejdsmæssig status, opsøgning af anden behandling i follow-up perioden, samt vurderinger af den indflydelse patienten mener behandlingen på E12 har haft på den aktuelle tilstand og situation.
Det skal bemærkes at SCl-90-R blev erstattet med Eysenck Personality Questionnarie (EPQ), samt items fra Minnesota Multiphasic Personality Inventory (MMPI) med henblik på validering af MCMI skalaerne, og med henblik på sammenligning med et tidligere psykoterapiprojekt på KAS Stolpegård. Desuden er en mindre gruppe patienter på det psykoterapeutiske ambulatorium yderligere testet med Rorschach før og efter behandlingen, samt ved 1.års follow-up. Ialt 60 patienter er indgået i denne del, der yderligere inkluderer Inventory of Interpersonal Problems (IIP), Defense Style Questionnaire (DSQ), samt Traume Symptom Checklist (TSC-35).