Mechanisms of change in focused psychodynamic therapy: A systematized single-case time-series analysis

Figures & data

Table 1. Heidelberg structural change Scale (HSCS, OPD Task Force, 2007; Rudolf et al., 2000, 2001)

HSCS stage	Description
1. Defensive rejection of the focus	Patient is not able to perceive the problematic focus. Both intrapsychic and interpersonal conflicts related to the focus are avoided, rejected, or normalized. The defense attempts are extremely successful, which is why the focal area has not yet become a problem for the patient to work on. This is why the patient is not aware of this problem area.
2. Unwanted presence of the focus	Patient begins to experience unwanted preoccupation and/or external confrontations related to the problematic focus. Begins to experience thoughts, unpleasant sensations, symptoms and/or interpersonal tensions related to the focus. The patient can no longer avoid these situations directly but does not identify her/his own responsibility for what is happening. Instead, she/he sees these problems as arising from external situations.
3. Vague awareness of the focus	Patient begins to become aware of her/his internal problem and/or interpersonal conflicts related to the focus, so that these situations can no longer be denied. Although she/he begins to identify her/his role in the focus, this conflicts with the patient’s own defensive efforts. She/he is still in a passive position in front of the problem area, but with therapeutic help, or because of the undeniability of the problem, she/he will be able to accept it progressively.
4. Acceptance and exploration of the focus	The patient develops for the first time a full awareness in relation to the focus, being able to locate her/his own role in the problem. From this, a frontal and active-exploratory approach to the problematic area emerges, which is not cancelled by the defenses that continue to take place on the part of the patient. There are great efforts by the patient to work on the focus in simple to modify it.
5. Dissolution of old structures in the area of the focus	Insecurities about oneself, others and situations related to the focus, together with sadness and despair begin to appear in the patient. She/he feels a sense of loss due to the questioning of what is already known (the problem focus). This generates a feeling of insecurity and perplexity since the benefits are still unclear. Moreover, efforts to make external changes no longer take place because the focus is on the internal. Although the patient experiences this in a very negative way, this is a step forward because (from the external point of view) he/she shows more permeability in the emotional and communicative sphere.
6. Reorganization in the focal area	The patient is again taking an active stance about her/his focal problem, as well as the unpleasant sensations are almost no longer present. In addition, she/he no longer needs old ways of functioning, but is able to carry out something new spontaneously. In this way, in relation to the problem area, the patient can develop new, more adaptive ways of experiencing and acting in her/his life.
7. Dissolution of the focus, problem integration	The patient has already overcome her/his problematic focus. She/he has been able to develop and integrate new modes of functioning. Thus, the focus is no longer a problem area in her/his life.

Table 2. OPD-2 foci identified by raters to assess structural change during treatment

OPD-2 Focus	Description
Relation (unconscious role offering)	Reject all the blame Lose himself/become confused when affection was shown Don´t set limits and allow too much closeness
Conflict Focus 1 Conflict Focus 2	Desires of care and protection versus self-sufficiency Oedipal conflict
Structure Focus 1 Structure Focus 2	Impulse regulation Ability to bond and detach

Figure 1. Trajectory of Gonzalo’s clinical severity during treatment: OQ.45.2 total scores.

Table 3. Multivariate vector autoregressive models performed (VAR, Pfaff, 2008)

Dep. Variable (time)	Predictors (time-1)	Estimate	Std. Error	t-value	p-value
OQ.45.2 total score	HSCS-Relation	1.88	1.12	1.68	.10 †
	HSCS-Conflict	0.08	1.44	0.06	.96
	HSCS-Structure	1.57	1.22	1.29	.20
	OQ.45.2 total score	0.61	0.12	5.06	<.01 *
HSCS-Relation	HSCS-Relation	−0.04	0–14	−0.29	.77
	HSCS-Conflict	0.23	0.19	1.23	.23
	HSCS-Structure	−0.12	0.16	−0.77	.45
	OQ.45.2 total score	0.01	0.02	0.18	.86
HSCS-Conflict	HSCS-Relation	−0.26	0.11	2.36	.02 *
	HSCS-Conflict	−0.13	0.14	−0.90	.37
	HSCS-Structure	0.02	0.12	0.20	.84
	OQ.45.2 total score	−0.00	0.01	−0.40	.69
HSCH-Structure	HSCS-Relation	0.16	0.13	1.23	.22
	HSCS-Conflict	0.34	0.17	2.06	.05 *
	HSCS-Structure	−0.00	0.14	−0.01	.99
	OQ.45.2 total score	−0.01	0.01	−0.60	.55

Dep.=Dependent; HSCS=Heidelberg Structural Change Scale; Std.=Standard.

Table 4. HSCS relation scores’ increase from one session to the next with narrative vignettes developed by raters

Session 6. HSCS Relation Score 2 Unwanted presence of focus

Symptomatic pressure is evident in his couple arguments with Laura, but Gonzalo rejects all the blame (core aspect of his relational focus) and is reluctant to take charge of the problem. He does not think that these conflicts are related to his person. Faced with the therapist’s interventions, Gonzalo disagrees, saying that he does not transmit anything to his partners to make them distrust him, leaving aside that this was a problem in all his relationships. In addition, he relates a similar situation with an ex-girlfriend, giving an account of previous relationships with this pattern.

Session 7. HSCS Relation Score 4 Acceptance & exploration of focus

The patient realizes that there is a problem that has to do with him, in this seeing Laura so often, which generates desires to have more time alone. He indicates having changed certain patterns that generated conflicts in the relationship. He says that he would have to say no to Laura to be with other women. He begins to have changes within the dysfunctional relationship pattern identified as a focus, by being more aware of his tendency to allow too much closeness, which in turn results in becoming confused when affection is shown

Table 5. HSCS conflict scores’ decrease from one session to the next with narrative vignettes developed by raters

Session 43. HSCS Conflict Score 4 Acceptance & exploration of focus

Patient and therapist talk about the way the relationship with Laura is related to his own way of functioning. Gonzalo identifies that he looks for spaces to be alone without his partner. He recognizes that he cannot stablish a healthy balance between the need for intimacy and the need for self-sufficiency, one of the conflict foci identified for the case.

Session 44. HSCS Conflict Score 3 Vague awareness of the focus

The patient is not very receptive to the therapist’s interventions. He says that he tries to include Susan more in his life but, at the same time, performs actions that speak to the contrary. He claims to be present with Susan, while he is also cheating on her and thinking about Laura. Gonzalo is vaguely aware of his conflictual need of being desired as a man (in line with the oedipal conflict identified as a focus). Also, there is a poor regulation between closeness and distance, in line with his conflict between the need for care and self-sufficiency, which is perceived only indirectly during the session.

Table 6. HSCS conflict scores’ increase from one session to the next with narrative vignettes developed by raters

Session 23. HSCS Conflict Score 3 Vague awareness of the focus

Gonzalo admits that he chooses a relationship to feel cared for, but at the same time he wants the freedoms of being with other people. He indirectly acknowledges he moves from wanting a stable relationship to wanting more independence, in line with his conflict focus of desire of care and attention versus self-sufficiency.

Session 24. HSCS Conflict Score 4 Acceptance & exploration of focus

A depressive mood is observed in the patient with much questioning of his actions. He explains that he wrote to Laura to find out if she was there, almost to confirm that she still existed. He fears that he no longer exists for them and that he is forgettable. He doubts why he went back to Susan right away because he felt good being alone. There’s more acceptance of his historical conflict with emotional distance and commitment.

Table 7. HSCS structure scores’ increase from one session to the next with narrative vignettes developed by raters

Session 44. HSCS Structure score 3 Vague awareness of the focus	Gonzalo talks about why he could not contain himself and tried to send a message to Laura. Therapist and patient talk about Gonzalo’s issues with impulse regulation (one of the structure foci identified for the case). In addition, Gonzalo mentions having been with another girl, but says it in passing, without giving it importance. There is little awareness of actions and their consequences.
Session 45. HSCS Structure score 4 Acceptance & exploration of focus.	Patient and therapist feel there was an improvement in this focus. Gonzalo reflects on his impulses and what he does with them. He understands that this leads him to have a lying relationship with Susan.

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Data availability statement

The research data associated with this study can eventually be requested to the Research Team in Clinical Psychology (EIPSI), Buenos Aires, Argentina (https://equipoeipsi.com/).