Sequential consequences of therapists' interventions.

Using sequential analysis, the authors examined how therapists' actions related to the verbal disclosure and defensive patterns that followed therapists' interventions within a single therapy hour for 20 patients. At the same time, a new measure, the Psychodynamic Intervention Rating Scale (PIRS), was tested for reliability and construct validity. Results indicated that therapists fit their styles of intervention to patients' levels of distress and functioning. Within the session, patient's emotional elaboration was followed by therapist's defense interpretation, followed by more patient emotional elaboration. Patient elaboration of significance was followed by more transference interpretation, followed by more patient elaboration of significance. Noninterpretive interventions were followed by patient's disclosure of facts, not emotion. Both interpretive intervention process sequences and therapist's use of support predicted posttreatment symptom reduction. The PIRS was shown to have satisfactory reliability and construct validity.

Diagnostic criteria for complicated grief disorder.

OBJECTIVE: Some prolonged and turbulent grief reactions include symptoms that differ from the DSM-IV criteria for major depressive disorder. The authors investigated a new diagnosis that would include these symptoms. METHOD: They developed observer-based definitions of 30 symptoms noted clinically in previous longitudinal interviews of bereaved persons and then designed a plan to investigate whether any combination of these would serve as criteria for a possible new diagnosis of complicated grief disorder. Using a structured diagnostic interview, they assessed 70 subjects whose spouses had died. Latent class model analyses and signal detection procedures were used to calibrate the data against global clinical ratings and self-report measures of grief-specific distress. RESULTS: Complicated grief disorder was found to be characterized by a smaller set of the assessed symptoms. Subjects elected by an algorithm for these symptoms patterns did not significantly overlap with subjects who received a diagnosis of major depressive disorder. CONCLUSIONS: A new diagnosis of complicated grief disorder may be indicated. Its criteria would include the current experience (more than a year after a loss) of intense intrusive thoughts, pangs of severe emotion, distressing yearnings, feeling excessively alone and empty, excessively avoiding tasks reminiscent of the deceased, unusual sleep disturbances, and maladaptive levels of loss of interest in personal activities.

States of emotional control during psychotherapy.

The authors' objective was to develop a simple and reliable descriptive method for categorizing patient states during psychotherapy. The categories would be based on the degree of apparent control over emotional expressions. Methods involved scoring videotapes of psychotherapy for 5 patients with neurotic-level Axis I disorders. Three judges rated each 30-second segment as predominantly one of these four states: well modulated, overmodulated, undermodulated, or shimmering. Shimmering states combine emotional display with efforts to stifle that expression. The results showed that judges could reliably rate states by the definitions used in this study. This technique can provide a simplified and general approach to observation of degrees of defensive control of emotion of patients in psychotherapy.

Signs of defensive control locate conflicted topics in discourse.

BACKGROUND: Psychodynamic clinicians cite defensive actions observed in evaluation and treatment as a source of important information. Empirical support for such assertions has seldom been based on objective study of recorded psychotherapy. A quantitative study of the association of signs of defensive control with disclosure of conflicted beliefs was undertaken. METHODS: Brief dynamic psychotherapies of two patients with pathological grief reactions were recorded and reviewed by independent judges. Periods of heightened defensive control of verbal and nonverbal communication were quantified using operational definitions. Reliably scored defensive episodes were algorithmically selected by computer programs. The people and topics discussed by patients were independently scored. RESULTS: Highly defensive periods contained disproportionately more frequent instances of patient discourse about people involved in conflict and unresolved topics. CONCLUSIONS: The findings support the psychodynamic hypothesis that observation of defensive behaviors may locate times of communication about conflicted themes.

Dysfluency and topic orientation in bereaved individuals: bridging individual and group studies.

Discourse of bereaved individuals talking about the deceased and other topics was examined using computer-based text analyses and judged ratings of verbal behavior for patterns indicating dysfluency and orientation toward topics. Using factor analysis, the discourse structure of low-distress bereaved individuals was compared with that of high-distress bereaved individuals and with that of single bereaved individual both early and late in psychotherapy. Meaningful differences were observed for the distress groups and for the single individual early and late in therapy, and these findings indicate possible quantitative and qualitative means for detecting maladaptive responses to stressors.

Cyclical patterns of states of mind in psychotherapy.

OBJECTIVE: A quantitative study of shifts in states of mind was conducted to demonstrate a clinically useful mode of observation. This mode categorizes observations of a patient's mental state into well-modulated, overmodulated, undermodulated, and shimmering patterns. METHOD: The authors used reliable systems for scoring a patient's state of mind on videotapes of all sessions of her brief psychotherapy and, using separate procedures, scored the topics of discourse. These data were then examined by means of a lagged log-linear sequential analysis for patterns of shifts from one state to another and for concurrent shifts in topics. RESULTS: The findings indicated nonrandom shifts in state. Patterns of shifting from a well-modulated state to alternative states and back again were overrepresented. Such shifts were related to conflictual topics of discourse. CONCLUSIONS: Observing such shifts in mental state may help psychotherapists to formulate the contents of conflict and also to make technical interventions to stabilize optimal states for doing the work of psychotherapy.

Expressive and defensive behavior during discourse on unresolved topics: a single case study of pathological grief.

Both psychodynamic and social-cognitive theoretical domains have control process models of behavior but with different ideas about the purpose and loci of control. This study examines expressive and defensive behaviors associated with different topics of discourse in the time-limited psychotherapy of a woman treated for pathological grief. Conceptually the study is based on a model of defensive control processes that integrates states of mind and person schemas. Theoretically derived measures of discourse topics, verbal and nonverbal defensive behaviors, emotional disclosure, and states of mind were applied to transcripts and videotapes of the entire therapy. Evidence from combined cluster and factor analyses supported the existence of recurring emotionally significant states. Two of these are particularly interesting from a clinical perspective: One, a "shimmering" state of intense emotional expression with concurrent signs of avoidance, was associated with topics identified clinically as stressful, unresolved, and conflictual. The other, a state of more uniformly stifled emotionality, was characteristic of discourse thought of clinically as resistance.

Pathological grief: an intensive case study.

Pathological mourning is such an excessive, blocked, or distorted process that psychiatric signs and symptoms develop. Explanation of how and why these signs and symptoms form could deepen an understanding of both normal and pathological mourning. Because many variables are involved in such explanations, intensive case study is a desirable methodology because it permits a detailed look at how various factors interact (Brewer and Hunter 1989; Luborsky and Mintz 1972; Luborsky and Spence 1971; Nessleroade and Ford 1985). While a patient may complain of symptoms as experiences that endure or occur episodically over days and weeks, a clinician observes psychiatric signs in the here-and-now seconds and minutes of an interview. Relating signs and symptoms to each other and to other variables in order to form a theoretical model of their formation requires exploration of data across long and short time frames. It is important to understand how the here-and-now phenomena combine to form patterns across longer periods of the individual's life. Hence, we developed a combined macro- and microanalytic approach to intensive case studies.

Topics and signs: defensive control of emotional expression.

This single-case study examined frank disclosure of important topics in a brief exploratory psychotherapy, including topics closely related to a recent, unintegrated stressor life event. Quantitative measures of emotion and control variables showed heightened levels of both emotionally and defensive control during discourse on the topic of the stressor event. In future studies, such measures of verbal and nonverbal signs of emotional expression and defensive control might be used to identify topics in an unresolved state.