Supervisors info:
Γρηγόριος Βασλαματζής, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ, Επιβλέπων
Δημήτριος Δικαίος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Στυλιανός Χριστογιώργος, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Summary:
One of the basic concerns of a psychodynamic psychotherapist is the possibility of a premature discontinuation of the therapy, particularly in patients with specific personality organizations or in difficult patients, since in certain cases this means the failure of psychotherapy.
Early discontinuation is generally considered the end of the psychotherapy that is decided unilaterally. If it is decided by the patient it is called dropout, whereas if it is decided by the therapist it is called forced discontinuation and it is mainly due to negative transference - countertransference.
There are two kinds of premature discontinuation derived from the patient: the early dropout occurs within the first 2-3 months of the therapy and the late dropout that occurs later. This time limit is conventional and depends on the therapeutic contract. A better limit would be whether premature discontinuation occurs before a therapeutic alliance is established.
The scientific goal of this study is to find whether there are early signs of premature discontinuation in psychodynamic psychotherapy
First we present a literature review of mainly psychoanalytic articles that deal with the problem of premature discontinuation in psychodynamic psychotherapy, in the general patient population, but also in special personality organizations. We make a summary of prodromal singes and factors that can be identified in the patient (demographics and clinical characteristics), and in the therapist through contertransference.
Patient's suitability for psychodynamic therapy is a very important characteristic that can lead to premature discontinuation, before the establishment of a therapeutic alliance. This is common in the treatment of patients with personality disorders (mainly borderline personality disorder). The clinical characteristics of borderline personality disorders can lead to premature discontinuation which is a major challenge for psychodynamic psychotherapy forcing the therapist to use more supportive technics.
Next, we try to show prodromal singes in two clinical examples. Specifically, we quote a case of a patient with early dropout (she stopped therapy after the 4th session, before the establishment of a therapeutic alliance) and a case of a patient with late dropout (she stopped therapy after the 16th session).
In the first case it is possible that the patient did not meet all criteria for psychodynamic psychotherapy. She did not have a high motivation for treatment despite the fact that she was experiencing a crisis situation. Furthermore, we did not manage to identify within the treatment the actual overlying problem, and there was not a prompt manage of the emerging transference and negative countertransference, due to the quick termination of therapy. In addition to the above, the patent’s demographic characteristics (age, gender, family and socio-economic status) could predict an early dropout.
In the second case the patient met the criteria for psychodynamic psychotherapy. In the beginning of the therapy she experienced the emergence of a negative transference before the establishment of a therapeutic alliance, but this did not persist throughout the course of psychotherapy. She experienced shifts of the transference and in the end there was a dropout from psychotherapy, which resulted from the mobilization of the patient's special defense mechanisms. The understanding of the prodromal singes in this case is based largely on data from countertransference.
Conclusively, this study demonstrates the need for systematic and standardized patient selection for psychodynamic psychotherapy and supervision, especially when we deal with inexperienced therapists, focusing on establishment and maintenance of the therapeutic contract (particularly in public clinics which provide psychodynamic psychotherapy).
