Change Process in Psychotherapy for Depressed Inpatient: A Case Within Trial Study

Abstract

Introduction Results of a randomized controlled trial supported the efficacy of a manualized, Intensive and Brief Psychodynamic Psychotherapy (IBPP) for inpatients with severe depression, but the mechanisms by which the interaction between a psychotherapist and a patient can be involved in a process of change require more direct study. Objectives The study aimed to explore how the psychotherapist and the patient interacted to work through the themes of focalization of their therapeutic work and how their work was part of a potential process of change. Methods A pragmatic case study was conducted on two cases selected from the umbrella study with one responder and one nonresponder to treatment (response defined as > 46% decrease in depressive symptoms on the MADRS). For each case, the verbatims of 6 sessions were analyzed, focusing on the themes of the IBPP manual. Results Two main functions were revealed: 1) “Becoming the subject of one’s depression”, which includes the following themes: i) “Following the Tracks of Pain and Loss”; ii) “Negotiating the Distance to the Cemetery”; iii) “Beginning to Accept”; iv) “Investing in New Projects “; and 2) “Regaining a sense of support” which includes the following themes: i) “Not Being Beaten Down”; ii) “Emptying a Full Closet”; iii) “Fear of Ending Up Alone”. The supportive interactions (regaining a sense of support) were present in a similar way in both cases, whereas the specific interactions (becoming the subject of one’s depression) were more present in the responder case. Conclusions In the psychotherapy of inpatients with severe depression, specific therapeutic interventions aiming to mobilize internal processes of symbolization, comprehension, and appropriation are necessary to reactivate a previously frozen mourning process. However, such interventions should be carried out in conjunction with interactions aiming to help the patient regain a sense of support. The central role of interactions that serve to build a therapeutic space and to restore epistemic trust was an unexpected result. It invites psychotherapists to pay particular attention to acknowledging a patient’s melancholic suffering, and to continuously seek to adjust their interventions to foster the continuity of emotional contact and the emergence of a sense of support. Theoretical and clinical implications of these findings will be discussed. Disclosure of Interest None Declared