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A Naturalistic Study of the Effectiveness of a Four-Session Format: The Brief Psychodynamic Intervention

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A Naturalistic Study of the Effectiveness of a Four-Session Format: The Brief Psychodynamic Intervention
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  A Naturalistic Study of the Effectiveness of a Four-Session Format: The Brief Psychodynamic Intervention Jean-Nicolas Despland, MDMartin Drapeau, PhDYves de Roten, PhD This study examined the effectiveness of the Brief Psychodynamic Intervention (BPI).The BPI is a 4-session intervention aiming at (a) developing an optimal plan to resolvethe patient’s crisis situation through the use of an initial dynamic interpretation and itsworking through, (b) providing information on indications for further therapeuticinterventions, and (c) furthering the development of early alliance. First, a pre–postdesign indicated that the BPI was effective in reducing symptom impairment with effectsizes of 0.38 for the SCL-90R Global Severity Index, 0.47 for the Hamilton Anxiety scale,0.69 for the Hamilton Depression scale, and 0.26 for the Social Adjustment Scale Global Adaptation Score. A cross-sectional design comparing 61 patients who had completedthe BPI with 61 patients on a waiting-list group indicated that the treatment accountedfor ( g 2 ) 17 %  of the variance in outcome. [ Brief Treatment and Crisis Intervention  5:368–378 (2005)]KEY WORDS: Brief Psychodynamic Intervention, BPI, effectiveness, outcome,brief therapy, intake, intervention, psychodynamic. Brief psychotherapies have gained in popular-ity in recent years. Since the early works of Alexander and French (1946), Balint (1971),Bellak and Small (1968), Davanloo (1978), andSifneos (1977), numerous short-term dynamictherapies (STDT) have been suggested fora wide range of disorders (e.g., Eglau, 1992;Leon, 1987; Magnavita, 1993; Moley, 1987;Oldham, 1988; Rockwell, 1987; Strupp &Binder, 1984). Efforts to obtain significantimprovement in patients in a short periodof time are the result of numerous factors.Aside from the many social causes and thewell-known pressures from government andprivate agencies to reduce the costs of thera-peutic interventions, many other factors havecontributed to the proliferation of STDTs,including an increase in the number of individ-uals recognizing their need for therapeutic From the University of Lausanne, Switzerland (Despland,de Roten) and McGill University, Canada (Drapeau).Contact author: Martin Drapeau, ECP–McGill University,3700 McTavish, Montreal, Quebec H3A 1Y2, Canada.E-mail: martin.drapeau@mcgill.ca.doi:10.1093/brief-treatment/mhi026 Advance Access publication October 5, 2005 368 ª The Author 2005. Published by Oxford University Press. All rights reserved. For permissions, please e-mail:journals.permissions@oxfordjournals.org.  help, the limited financial resources of manypatients or institutions, various crisis situa-tions, a need for prevention in mental health,and the patients’ growing expectations toimprove significantly and fast.Results from the early studies of Balint(1971) and Malan (1963, 1976) supported theeffectiveness of STDT. However, in a meta-analytic review of 19 studies, Svartberg andStiles (1991) found that brief dynamic thera-pies achieved a small effect size and that at 6months follow-up it was no more effectivethan a waiting list. Furthermore, their findingssuggested that STDT was significantly lesseffective than the treatments with which itwas compared. On the other hand, Crits-Christoph’s (1992) meta-analytic review of 11studies indicated that STDT produced effectsizes of 1.10 for target symptoms, 0.82 forgeneral symptoms, and 0.81 for social adjust-ment. These dissimilar results are thought tobedue totheinclusion criteriaforeach of thesemeta-analyses. Unlike Svartberg and Stiles,Crits-Christoph examined studies where treat-ment manuals were employed.More recently, the meta-analytic review of Anderson and Lambert (1995) of 26 STDTstudies showed that STDT was effective, witha general effect size of 0.71relative to a waiting-list control group. They also demonstrated thatSTDT produced a small effect size of 0.34relative to minimal treatment conditions, andno differential effectiveness relative to alterna-tive treatments.However,thestudiesexaminedin their meta-analysis included therapies of up to 40 weeks duration. This is also the casefor the meta-analyses conducted by Crits-Christoph (1992) and Svartberg and Stiles(1991). With the exception of some studies inhighly specialized fields (e.g., Miller, 2000;Thom, Sartory, & Johren, 2000), little is knownabout the effects of ultrabrief therapies, al-though accumulating evidence on the effective-ness of short-term therapies has recently drawnclinical attention to what Bloom (2001) refersto as the ‘‘extreme case’’—therapeutic inter-ventions based on one single session. Eventhough additional controlled outcome studiesare needed, preliminary findings suggest thatsingle-session psychotherapy may be effectivein achieving diverse clinical goals (for a review,seeBloom,2001).Otherultrabriefmodelsincludethe two-plus-one model, which has been shownto be effective with patients suffering fromsubsyndromal depression (Barkham, Shapiro,Hardy, & Rees, 1999). Nonetheless, informationon the effectiveness of ultrabrief therapies isscarce.This paper first aims at presenting anultrabrief psychodynamic intervention thataddresses the dynamic and systemic processesat work in individuals and in the therapeuticsettings. Finally, it reports preliminary resultson its effectiveness. The Brief Psychodynamic Intervention The Brief Psychodynamic Intervention (BPI),previously referred to as the Brief Psycho-dynamic Investigation, was developed inLausanne, Switzerland. Details on the BPItechnique are available elsewhere (Gillie´ron,1987, 1989a, 1989b, 1994, 1997; Gillie´ron & deRoten, 1996). In summary, the BPI is a crisisintervention that focuses on both the patient’sconscious and unconscious reasons or motivesfor consultation. The main objectives of the BPIare to develop an optimal plan to resolve thepatient’s crisis situation through the use of aninitial dynamic interpretation and it’s work-ing through. As such, it is not unlike the two-plus-one model (Barkham et al., 1999). Whenadditional treatment is required following theBPI, this four-session format has the advantageof allowing the clinician to assess the patient’sresources for psychotherapeutic treatment andto further the development of the early alliance. Brief Psychodynamic Intervention Brief Treatment and Crisis Intervention /  5:4 November 2005  369  As such, it is in agreement with the AmericanPsychiatric Association’s practice guidelinesfor the evaluation of adults (American Psychi-atric Association [APA], 1996).A BPI first involves a 10- to 15-min telephonecall from the assigned therapist to his patient.This call entails a brief exploration of thepatient’s difficulties and explains the generalformat of the BPI. As the sessions begin, theBPI involves rapidly drawing up a psychody-namic hypothesis pertaining to the crisisexperienced by a patient. This hypothesis isbased on the dynamic relationship establishedbetween the therapist and the patient at thevery early stages of the intake interview(pretransference). It is also based on thepatient’s present crisis, his personality organi-zation, and his core relationship patterns(Luborsky, 1998). Using this information, thetherapist works on an intervention in the formof an interpretation. This interpretation shouldaddress (a) the present crisis experienced bythe patient and the relational context in whichthe symptoms have appeared, (b) the necessarychange with which the subject is confronted asa result of the crisis, (c) the intrasubjectiveconflict the subject must face as a consequenceof the crisis and if he or she is to resolve thiscrisis, and (d) the meaning of the symptoms ascompromise formations. This initial interpre-tation is given at the end of the first intakesession or at the very beginning of the secondsession. Sessions 2 and 3 involve workingthrough this initial interpretation with thepatient. Finally, the last session is used toreflect on the three previous sessions and drawconclusions. This last session is also used todecide if further treatment is required and, if so, to determine what kind of treatment wouldbe most beneficial to the patient. A recentmanual guides this four-session method of intervention. When the technique is rigor-ously applied, almost no dropouts occur(Gillie´ron & de Roten, 1996). Method Patients  The complete sample included 122 self-referredoutpatients from the Adult Psychiatry Out-patient Unit of the University of Lausanne(Switzerland). All subjects were assigned toa BPI. The general criteria for participation inthe study included 17–60 years of age anda minimum of one diagnosis related to anxiety,depression, or personality disorders. Exclusioncriteria included organic or delirium disorders,substantial alcohol or drug dependence, psy-chotic or bipolar disorders, mental retardation,and antisocial personality disorder.Of the complete sample ( N   ¼  122), the first61 patients (hereafter referred to as the ‘‘treatedgroup’’) had already completed the BPI. Thetreated group included 24 men (39%) and 37women (61%) with a mean age of 29.13 ( SD ¼ 9.18). Most of these patients were seekingtherapeutic help for mood (62.3%) or anxietydisorders (36.1%), and occasionally for eating(4.9%), sexual (4.9%), or substance-abuse-related (3.3%) disorders. Some comorbidity wasdetected as the mean number of Axis I diag-noseswastwodisorders.Finally,38%presenteda Cluster C personality disorder on Axis II.The other 61 patients (hereafter referred to asthe ‘‘waiting-list group’’) had just recentlystarted a BPI and had not yet completed it.Unlikethepatientsfromthetreatedgroup,thosefromthewaiting-listgroupwereaskedtofilloutquestionnairessenttothembymailimmediatelyafter their first call for an appointment, andhence approximately 1 month before the firstappointment.Assuch,thesepatientshadalreadybenefited from the routine BPI telephone call,which lasts from 10 to 15 min, and from the firstBPI session. Forty-four percent of the patientswere women. The mean age was 32.38 ( SD  ¼ 11.21). These patients were seeking therapeutic DESPLAND ET AL. 370 Brief Treatment and Crisis Intervention /  5:4 November 2005  help for mood (86%) or anxiety disorders(36.3%),andoccasionallyforeating(9%),sexual(4%), or substance-abuse-related (3.1%) disor-ders.Onceagain,somecomorbiditywasdetectedas the mean number of Axis I diagnoses was 1.5disorders. Finally, 43% presented a Cluster Cpersonality disorder on Axis II.Reliability of the clinical diagnoses in bothgroups was established on a subsample of 36patients using the Guided Clinical Interview(Perry, 1995). It was shown to be satisfactorywitha j ¼ 0.65forAxisIand j ¼ 0.54forAxisII. Therapists  The BPIs were conducted by three female andsevenmaletherapistsfromtheAdultPsychiatryDepartment of the University of Lausanne. Onetherapist was a licensed psychologist, whereasthe other nine were licensed psychiatrists. Allhad had prior training in BPI. Five wereconsidered to be senior therapists with a mini-mum of 5 years of experience in BPI, whereasthe remaining five were considered to be juniortherapistswithlessthan5yearsofexperienceinthe technique. However, the therapists fromboth groups had much experience in thepractice of psychodynamic therapy witha mean of 19 years of experience (ranging from8 to 38 years). Furthermore, the therapists wereassessed using the BPI Adherence–Competencescale (Tadic & Despland, 2001). Despite smalldifferences in competence between the juniorand the senior therapists, all therapists wereshown to be highly competent in BPI (Tadic,Drapeau, de Roten, Solai, & Despland, 2003). Instruments  The patients from the first wave (the treatedgroup) were asked to fill out the SCL-90R(Derogatis, 1994) immediately before the intakesession and after the last session. The secondwave of patients (waiting-list group) wasrequired to fill out the symptom checklistsoon after their first call to set an appointmentand hence 1 month before the first of the BPIsessions, as well as immediately before their BPIintake. The SCL-90R includes 90 items address-ing various somatic and psychological signs of distress. These items are scored using a Likert-type scale from 0 ( not at all ) to 4 ( very much ).Although the instrument includes 10 subscales,this study only made use of the Global SeverityIndex (GSI; score ranging from 0 to 4), whichrefers to the mean rating across all items.The Hamilton Depression (HAMD—21 items)and Anxiety (HAMA—21 items) scales werealso administered to 31 of the 61 treatedpatients by experienced clinicians. This wasdone immediately before the first session andright after the last session. Unfortunately,because the HAMD and the HAMA were addedto the protocol at a later time, data are notavailable for the complete sample.The Social Adjustment Self-Rated scale (SAS-SR; Weissman & Bothwell, 1976) is a 54-question self-rated scale used in order to assessa patient’s interactions with his environment.The scale addresses an individual’s functioningand level of satisfaction in various social roles,including work, leisure, family, children, in-timate relationships, and material situation. Ascore ranging from 0 (  good adjustment/satisfac-tion ) to 5 ( bad adjustment/satisfaction ) can thenbe calculated for each of these six subscales.However, as few patients in this study hadchildren or a spouse, we analyzed all subscalesindividually with the exception of the onesrelated to children and to intimate relation-ships. The Global Adaptation Score was alsocomputed as a mean across all items. The SAS-SR was given to the treated patient group atintake and after the fourth session. Study Design and Data Analysis  This study was partly longitudinal and partlycross-sectional. The  longitudinal aspect  of the Brief Psychodynamic Intervention Brief Treatment and Crisis Intervention /  5:4 November 2005  371  design involved examining change for 61patients before and after a BPI. A paired-samples  t  test was used in order to assess thesignificance of change on all measures for thegroup of 61 patients who had completed a BPI.Hence, the tests were computed to comparebeginning-of-treatment (immediately beforethe first session) and end-of-treatment. Further-more, within-subjects effect sizes (WESs) werecalculated in order to quantify the importanceof change on all measures. As change in meanswas the focus of the intervention, effect sizeswerecalculatedbysubtractingthe t 1 meanfromthe  t 2  mean and dividing this difference inmeans by the pooled standard deviation.In order to facilitate comparison with otheroutcome studies, the proportion of patientswithin nonclinical norms for the GSI wascomputed. The upper nonclinical cutoff wasset at two normal population standard devia-tions above the normal population mean. AsDerogatis (1994) suggested a normal populationmean of 0.31 ( SD ¼ 0.31), we considered a scoreof 0.93 to be the cutoff between clinical andnonclinicalcases.Tingey,Lambert,Burlingame,and Hansen (1996) have also suggested a GSImeanof0.19( SD ¼ 0.16)foranasymptomaticorvery healthy and high-functioning sample (seealso Hilsenroth, Ackerman, & Blagys, 2001).The proportion of subjects scoring within themean plus 2  SD  of this second cutoff was alsocomputed to determine how many subjectscould not only be considered as nonclinicalcasesbutalsobeconsideredashigh-functioningand psychologically healthy cases.For the HAMD and HAMA scales, cutoff scores were set at 2  SD  above the normalpopulation mean (Hinz & Schwarz, 2001). Forthedepressionscale,acutoffscoreof9wasusedto distinguish depressed subjects from normalpopulation norms. For the anxiety scale, thecutoff score was determined to be 11. Thesescores were used to determine the proportion of patients entering normal population norms.Finally, the cutoff score for the SAS globalscore wasalso set at 2  SD  above the normalpop-ulation mean (Weissman, Pursoff, Thompson,Harding, & Myers, 1978). Hence, a cutoff scoreof 2.25 was used to determine the proportion of patients within normal population norms.The  cross-sectional aspect  of the study in-volved comparing the 61 patients who hadcompleted a BPI (treated group) with a group of 61 patients who had just recently started a BPI(waiting-list group). These last patients werefirst put on a waiting list and assessed 1 monthbefore the beginning of the BPI and againimmediately before the intake session. Becausea BPI involves four weekly-held sessions,comparing change in the treated group in 1month of psychodynamic intervention withchange in 1 month while on a waiting listbecame possible (these last patients did, how-ever, receive the routine telephone call fromtheir assigned therapists).First, a  t  test was used to determine if the twogroups were different at  t 1  on the SCL-90R GSI.Because the groups were significantly different,we used a more conservative approach andapplied the multivariate analogue of the analysisof covariance model (ANCOVA) using pretreat-ment assessments as covariates in order tocompare both groups at  t 2 . To compare bothgroups individually, the WESs were also calcu-lated for the waiting-list group. Finally, the etasquare was used to assess between-subjectseffect size. The eta-square indexes the per-centage of total variance explainable by differ-ences in the independent variable (in this case,the BPI). Results Change in the treated group  Results indicated that the GSI was significantlylower at the fourth session than at intake, DESPLAND ET AL. 372 Brief Treatment and Crisis Intervention /  5:4 November 2005
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