Predicting a rapid response during psychotherapy for depression

Transcription

1 University of Wollongong Research Online University of Wollongong Thesis Collection University of Wollongong Thesis Collections 2008 Predicting a rapid response during psychotherapy for depression Andreas Comninos University of Wollongong Recommended Citation Comninos, Andreas, Predicting a rapid response during psychotherapy for depression, PhD thesis, Department of Psychology, University of Wollongong, Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library: research-pubs@uow.edu.au

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3 Predicting a Rapid Response During Psychotherapy for Depression A thesis submitted in partial fulfilment of the requirements for the award of the degree Doctor of Philosophy (Clinical Psychology) from University of Wollongong by Andreas Comninos, B.Psych (Hons) School of Psychology 2008

4 This thesis is dedicated to my Gramps John J. Webb-Wagg (05/11/ /10/2005) An incredibly inspiring father figure and a truly tremendous human being iii

5 Thesis Certification I, Andreas Comninos, declare that this thesis, submitted in partial fulfilment of the requirements for the award of Doctor of Philosophy, in the School of Psychology, University of Wollongong, is wholly my own work unless otherwise referenced or acknowledged. The document has not been submitted for qualifications at any other academic institution. Andreas Comninos. June, iv

6 Acknowledgements I express my deepest gratitude to the many people who contributed to this work: I sincerely thank my wonderful supervisor Associate Professor Brin F. S. Grenyer who illuminated the path with his wisdom, experience, and unwavering support throughout the duration of this project. Your funding of my international conference debut at SPR in Rome 2004 was a colossal financial commitment that encouraged me immensely. Your generous gesture, and my resulting positive presentation experience, gave me the confidence to continue along this path of psychotherapy research. I also thank my lucky stars for the love, help, support and encouragement of my mother, Carol (THANKS MUM ), and her husband John, who put me up and (so often) put up with me. I would never have finished in time without the opportunity that living with you provided me. To my closest and dearest friends: Thank you for helping by continually reminding me who I am, and by distracting me; your tireless input continued to keep my head above grey clouds. Some of these people include, Luke, Sarah, Tristan & Tara, James & Leonie, Ty, Amy, Clint & Jussie, Thea, Clair, Greg & the Buchans, and me mate Dave. I am particularly grateful for the wonderful people and experiences of the infamous Bronte Period : My heart has been lit aglow with memories that will no doubt last a lifetime. A special mention goes to Glen, who helped by giving me the expertise to build / fix computers and acquire the software required to complete my PhD. I also express a special appreciation for the love and support of Kirsten and her family, who supported me through my undergraduate degree, and the early stages of my post-graduate training. Dr Evelyn Howe (University of Sydney) & Dr Hamish McLeod (University of Wollongong): Thank you for your support, encouragement and "tough love". You helped me to knuckle down during the last leg of it the shortest, but toughest leg by far. Anne Devlin: Thank you for your enthusiastic assistance with the scoring of the data for Study 2. Thanks also to Trevor Crowe, Michelle Greene, and Samantha Reis for your previous efforts gathering and entering data for many of the measures I used. Finally, I thank the patients of this study, without whom this work would not have been possible. A 4-year stipend in the form of a Clinical Psychology Award (CPA) from the University of Wollongong supported the work of this thesis. v

7 Abstract Rationale. According to sudden gains and rapid response methods, considerable numbers of patients experience large robust reductions in depression in early sessions across a range of psychotherapeutic modalities. Yet, surprisingly few researchers have investigated the processes that might help explain this phenomenon. Aims. Accordingly, the aims of this thesis were threefold: 1) To replicate previous findings of a rapid response to psychotherapy, 2) To investigate the role of empirically supported pre-existing interpersonal patient factors, 3) To examine systematically the therapeutic processes that characterise both rapid and gradual response profiles. Methods. Sixty-two adults received 16 weekly sessions of supportive-expressive dynamic psychotherapy (Luborsky et al., 1995). A rapid response was defined as a reduction of at least 50% of patients intake Beck Depression Inventory score by Week 6. Following a comparison between rapid and gradually responding patients attachment and interpersonal patterns, 20 (10 rapid-, 10 gradual-responders ) early therapy sessions (session 3) were rated with the Psychotherapy Process Q-Set (PQS; Jones, 2000). The PQS is a pan-theoretical method of systematically characterising therapist-patient interactions that provides a meaningful index of process that can be used in comparative analyses. Results. Over one third of patients (23/62) experienced a rapid response, by Session 6. This accounted for an average 96% of their entire symptom reductions. Rapid responders were more than twice as likely to recover by Session 16, and were significantly less depressed at 52 week follow-up, after adjusting for intake symptom levels. Rapid responders also presented with fewer interpersonal problems. On the other hand, pre-therapy characteristics of gradually responding patients included having lower interpersonal mastery, a more domineering interpersonal style, and greater social isolation and attachment fears concerning intimacy. The interpersonal differences between rapid and gradually responding patients were reflected in differences in psychotherapy processes. Despite equivalent ratings of observer-rated working alliance, results from the PQS suggested that as early as Session 3, rapid responders were at a more advanced stage of therapy, characterise d by a willingness to work on strong emotions such as guilt. In contrast, gradual responders sessions were dominated by externalising, hostility, and defensiveness. Conclusion. Pre-existing interpersonal patient factors determine the speed of vi

8 recovery in psychotherapy through their differential effects on therapeutic processes. vii

9 Contents Thesis Certification Acknowledgements Abstract List of Tables List of Figures List of Appendices List of Publications Arising From This Thesis iv v vi xi xii xiii xiv Chapter One Introduction The Prevalence of Depression The Effectiveness of Psychotherapy for the Treatment of Major 2 Depression 1.3 Sudden Gains and a Rapid Response Sudden Gains Sudden Gains in Psychotherapy for Depression Sudden Gains in other Disorders The Importance of Early Gains Sudden Gains and Cognitive Change: Where s the Evidence? The Contributing Factors of Change in Therapeutic Processes Problems with the Sudden Gains Method A Rapid Response: The Way Forward A Rapid Response to Psychotherapy for Depression A Rapid Response in Other Disorders Summary: Sudden Gains and a Rapid Response Non-Specific and Extra-Therapeutic Factors Personality Interpersonal Experiences Patients Bring to Therapy 23 viii

10 Chapter Two Study 1: Predicting In-Session Depression Outcomes Aims Method Data Source Measures Procedure Results Identification of an ERR Recovery Interpersonal Mastery Attachment Self-Reported Interpersonal Functioning Therapeutic Alliance Demographic Variables Diagnostic Severity The Impact of External Events Study 1 Discussion 38 Chapter Three Study 2: An Analysis of the Interior of Early Sessions Measuring Psychotherapy Process Aims Research Questions Method Data Source Measures Procedure Data Analyses Results Most and Least Characteristic PQS Items Differences in Therapy Process Across Both Groups 56 ix

11 3.5.3 Process Correlates of Treatment Gains in Supportive-Expressive Working Alliance and Countertransference Study 2 Discussion 61 Chapter Four General Discussion Integration of Findings Limitations Implications and Future Directions Sudden Gains and a Rapid Response Revisited Conclusion 75 References 77 Appendices 89 x

12 List of Tables Table 1. Table 2. Table 3. A Comparison of the Excluded (n = 30) and Retained Patients (N = 62) Characteristics at Intake 29 Demographic and Treatment Variables of Sample Investigated (N = 62) 30 Symptomatic Severity between ERR and non-err patients at Intake, Week 6, Week 16, and Week Table 4. Patient Characteristics of the ERR and non-err subsample 50 Table 5. Rank Ordering of Q-Items for ERR Patients (n = 10) 55 Table 6. Rank Ordering of Q-Items for non-err Patients (n = 10) 56 Table 7. Table 8. Differences Between Q-Item Means for ERR and non-err Patients 58 Process Correlates of Treatment Gains in Supportive-Expressive Therapy (N=20) 60 Table 9. An Examination of Working Alliance and Countertransference 60 xi

13 List of Figures Figure 1. The hypothetical data of three patients with sudden gains 13 Figure 2. Comparison between mean Beck Depression Inventory (BDI) symptom ratings of early rapid response (ERR) and non-err patients at each session (week) interval 34 Figure 3. Differences in Mastery Scale category frequency between early rapid response (ERR) and non-err patients 36 xii

14 List of Appendices Appendix A The Original Sudden Gain Criteria 89 Appendix B The Impact of External Events Questionnaire 90 Appendix C Jones s Psychotherapy Process Q-Set items (Jones, 2000) 91 Appendix D PQS Scoring Procedure 93 Appendix E The Inventory of Countertransference (Friedman & Gelso, 2000) 94 xiii

15 List of Publications Arising From This Thesis Comninos, A., & Grenyer, B.F.S. (2008). Patient-therapist interactions in early therapy sessions predict sudden gains and outcomes. 39th Annual Meeting of the Society for Psychotherapy Research, Barcelona, Spain, June. (This work received the Enrico E. Jones Memorial Award.) Comninos, A., & Grenyer, B.F.S. (2007). The influence of interpersonal factors on the speed of recovery from major depression. Psychotherapy Research, 17, Comninos, A., & Grenyer, B.F.S. (2007). A rapid response to psychotherapy for depression: A qualitative and quantitative analysis of therapy process. In Grenyer, B.F.S., King, R., Crowe, T., Deane, F. (Eds). Evidence-Based Psychotherapy: Proceedings of the 2007 Australia Psychotherapy Research Group Meeting. Wollongong: Illawarra Institute for Mental Health, University of Wollongong. (This work was awarded the Best Conference Presentation prize.) Comninos, A., & Grenyer, B.F.S. (2007). Optimising treatment response for depressive disorders: A clinical model. In Grenyer, B.F.S., King, R., Crowe, T., Deane, F. (Eds). Evidence-Based Psychotherapy: Proceedings of the 2007 Australia Psychotherapy Research Group Meeting. Wollongong: Illawarra Institute for Mental Health, University of Wollongong. Grenyer, B.F.S., Comninos, A., & Luborsky, L. (2006). Sudden gains and mastery of relationship conflict in supportive-expressive dynamic psychotherapy. 37th Annual Meeting of the Society for Psychotherapy Research, Edinburg, Scotland, June. Comninos, A., & Grenyer, B.F.S. (2004). The preconditions of an early rapid response to psychotherapy for chronic depression. The MHS : The Mental Health Services Conference, Gold Coast, September. Comninos, A., & Grenyer, B.F.S. (2004). The preconditions of an early rapid response to psychotherapy for chronic depression. 35th Annual Meeting of the Society for Psychotherapy Research, Rome, Italy, June. Deane, F. P., Grenyer, B. F. S., Comninos, A., Gatto, L., & Todd, D. (2004). Psychotherapy careers: Treatment history and its relationship to outcome in supportive-expressive psychotherapy for depression. Paper presented to the 35th Annual Meeting of the Society for Psychotherapy Research, Rome, June. xiv