Experimental study of person-centered psychotherapy effectiveness (based on sample with chronic gastrointestinal diseases). Part I

Bondarenko A.F., Maksimenko K.S. (Kiev, Ukraine)

Abstract

This article touches upon the problem of Person-centered psychotherapy in the treatment of specific psycho-emotional problems which are caused by chronic physical illnesses.

The study involved the patients with chronic diseases of gastroenterological spectrum on the exacerbation stage. Total sample size was 144 people: 85 females (59.09%) and 59 males (40.01%) at the age from 24 to 59 y. The average duration of therapy ranged from 15 to 20 hours.A separate group of patients (15 people) were treated with medications prescribed by a psychiatrist in accordance with psychopathological report taking into account the basic diagnosis (anxiolytic, sedative, nootropic, anti-depressants).

Methods. At the sample selection and the final stages the MMPI, M. Lüscher Colour Test and L. Szondi Test were applied. Before each psychotherapy session and after it: Express-diagnostics on the basis of SAM- techniques (self-esteem, activity, mood), in form of personal semantic differential.

Results and conclusions. The most significant results in the clinical sense (health, strengthening, stress reduction, reduction of scales, indicating the severity of the reactive state, positive dynamics of the lab tests, etc.) have been observed in group of patients receiving concomitant (psychological, pharmacological and nosology-oriented) therapy. It can be assumed that the various psychotherapeutic approaches should be considered as subsidiary, rather than independent means of chronic illness treatment. Purely psychological methods will be useful for the emotional abreaction, switching attention from the dominant physical suffering to the patient’s personal resources, as well as self-presentation processes.

Key words: medical psychology; somatogenic; gastroenterological diseases; chronic illness; existential-humanistic psychotherapy.

 

Received:
January 25, 2017

Accepted:
February 19, 2017

Publisher:
April 26, 2017

  For citation  

 

 

Problem Statement

The medical and paramedical activities, including psychotherapy in the broadest sense of the word, are the special and perhaps most important public spheres. The development of these particular branches of modern medical (clinical) psychology gained in our time considerable importance in solving a wide range of issues related to the provision of psychotherapeutic aspects of patient care. This especially concerns the patientswhose diagnoses belong to the so-called "small psychiatry" and in particular those who suffer from emotional problems caused by a chronic somatic illness. The last one may not only negatively affect the patient’s mental states, but also cause permanent personality disorder (which according to the International Classification of Diseases (ICD-10) are of V-Classand are designated by the code from F 60.0 to F 60.09). The analysis of psychotherapy researches as well as specific processes in psychotherapy on the territory of the former Soviet Union suggests: more and more researchers are trying to set a proper theoretical task to determine exactly which model of psychotherapy (traditional and new) and in what way may be the most effective inovercoming the psychological problems of a person who suffers from chronic somatic and psychosomatic diseases ([1; 2; 3; 4; 5; 6; 9; 11; 12; 13; 14; 15; 16; 17; 18; 19; 20; 21; 22; 23; 24; 25; 26; 27; 28; 29; 30; 31; 32] etc.). Thus, the actual experience indicates the urgent need for studying the real possibilities of modern psychotherapyin the matter of treatment the sufferings, in which the person can’t resist the strain not due to the neurochemical / organic brain and nervous system damage,but as a result of psycho- and somatogenic disorders, which were caused by chronic painful physical conditions. In our opinion, this problem field requires special attention at the present stage of development of medical (clinical) psychology.

Subjects

The study involved the patients with the exacerbation stage of the following chronic diseases of gastroenterological spectrum: various types of chronic gastritis with normal or increased gastric secretory function as well as with secretory insufficiency: simple, catarrhal, hemorrhagic gastritis; chronic cholecystitis and angiocholitis (cholangitis), taking into account patients after cholecystectomy; gastric and duodenal ulcers; gastroesophageal reflux disease, chronic ulcerative colitis, including chronic colitis of various localization (sigmoiditis, proctitis, proctosigmoiditis), as well as irritable bowel syndrome.

Total sample size was 144 people: 85 females (59.09%) and 59 males (40.01%) at the age from 24 to 59 years.

The initial psychodiagnostic examination of patients was performed using the short version of the MMPI test and Lüscher Color Test. Officially procedure was called the "current state assessment". At the end of the psychodiagnostic procedure, the psychologist briefly discussed the results with the patient, asking if he was interested in work on "stress reduction": in individual or group form.

Those patients whose psychogram were of the research interest and who were willing to work with the psychologist or therapist had additional interviews with a "psychoneurologist" (as officially a psychiatrist was named). At a separate closed meeting of the project supervisor (Prof. Bondarenko A.F.), an expert consultant (cand. of psychol. science Maksimenko K.S.) and a psychiatrist, the final decision was made whether to include each patient in a target cohort or just to provide an opportunity to participate in psychotherapeutic work. Each patient, who expressed desire to participate in the psychotherapeutic work, passed L. Szondi diagnostic test (version adapted by Sobchik L.M.) and received a printout of the diagnostic conclusion that created a natural occasion for the beginning of person-oriented therapy. Additionally, prior to each individual or group session and after it, each participant filled out the express-diagnostics test on the basis of SAM-test (self-esteem, activity, mood), but in form of personal semantic differential. In this way the research team carried out a constant monitoring of the patient current state, which increased the interest of the participants in psychotherapy and at the same time provided certain feedback to a psychologist. Due to the specifics of the research project, the psychologists, working with different groups of patients, were not initiated into the subtleties and nuances of nosological diagnosis and were not informed that other groups of psychologists in other medical institutions are working with the same patient population. In other words, psychologists have not been introduced to the sense of the super task of this study, although the common setting for them was that the group of patients need psychotherapy aimed at reducing personal stress associated with Forced hospitalization. Thus, we complied with conditions relating to the requirements of the double-blind method in a pilot study*. After completing the participation in psychotherapeutic sessions, the patient reperform the diagnostic programs, so that the project supervisor (prof. Bondarenko A.F.) and consultant expert (Cand. Sc. (Psychology) Maksimenko K.S.) had the opportunity, together with a psychologist, psychiatrist, and doctor thoroughly and comprehensively analyze the dynamics of the patient’s personality and psychotherapeutic effect.

The psychotherapeutic session was conducted daily from 16.00 to 17.30 six times per week (daily except Sunday). The average duration of psychotherapy for patients ranged from 15 to 20 hours. Some people (9) expressed the desire to continue individual psychotherapy after discharge from the hospital, and received an additional from 6 to 10 hours of psychotherapy. The certain difficulties were imposed by the norms of the bed-hours, actually allocated per patient in modern hospitals (e.g. no more than 14 bed-days per patient in the gastroenterological department). During our project, the actual length of patient hospital stay rarely reached three working weeks. Itcan be argued that such psychotherapeutic treatment actually corresponds to the life style of modern megalopolis inhabitant, andfits into the canons of short-term psychotherapy. And let’s not forget thatour target group consists of patients of a somatic rather than a psychiatric profile. Therefore, they naturally have a different attitude to psychotherapy, as well as psychotherapists have it in relation to such patients.

The special attention should be paid to that part of the cohort of targeted patients (15 people) who took special medications prescribed by psychiatrists in accordance with the psychopathological diagnosis as were agreed with the attending physician, taking into account the main diagnosis. In general, prescription drug list included anti-anxiety drugs (Afobazol, Strezam, Xanax, etc.); sedative (Glycine, Glycide, etc.); nootropic drugs (Noophen, Pantogam, Nootropil, Glycine, etc.), as well as a group of antidepressants of both plant origin (Life-900, Gelarium-Hypericum, Deprim), and of the SSRIs-group (Ciprolex, Citalopram, Fluoxetine) and SOSSN (Venlafaxine, Duloxetine), and in case of secondary insomnia — Sonovan (Zopiclone), Vita-melatonin or, if necessary, Agomelatine (Melitor). The main research aspect was that this part of the cohort was divided into two groups. One of them (7 people)was limited to taking the above mentioned drugs, and the other (8 people) took part in psychotherapy in addition to prescribed medications. The difficulty lied in the fact that, as a rule, most of these drugs are appointed for a period much longer than the timing of the psychotherapy itself.

In addition, the effects of many of them begins to manifest in 10—12 days, so the objective mismatch between psychotherapeutic interventions and pharmacodynamics, taking into account the "respondent-non-respondent" criterion, was another important nuance of this research project. In order to ensure effective treatment, special attention was paid to feedback issues, including delayed feedback via e-mail, and the possibility, if necessary, contact the project supervisor, and then — the psychiatrist for a prescription, etc.

Results and analysis

The dynamics of patients’ psycho-emotional and physical condition after the Existential-Humanistic psychotherapy. At the first stage of the psycho-emotional state assessment, the presence of changes in the subjective assessment of the patient’s emotional state was analyzed using the semantic differential technique. Since the values of the scales of the modified version of the semantic differential, proved to be sufficiently homogeneous, we analyzed the average values for the whole group of each scale. As can be seen from the graph of Figure 1, the dynamics of the indicators for each of the scales is sufficiently explicit. The most obvious improvement of well-being observed on the scale of "bad — good". The patients felt more relaxed and comfortable after a group therapy.

 

 

Figure 1. Dynamics of subjective assessment of patient’s emotional state 
(mean values on the scales in the group) before and after the group therapy course
in existential-humanistic paradigm (based on semantic differential).

 

It is worth noting that the figures for all the scales in the diagnosis after the psychotherapeutic course vary within no more than the average level of expression (1.5 points on the SD scales). High rates, reflecting the positive subjective assessment of the patients are not available, which gives us the ground for the assumption that exclusively psychotherapeutic measures are insufficient to improve the psycho-emotional state of patients.

The dynamics of the subjective assessment of the patient’s physical condition is also positive and sufficiently expressed (Figure 2). The indicators for all scales tended to a positive pole, but also within the framework of the average level.

 

Figure 2. Changes in the subjective assessment of the physical condition of the patients
(mean values on the scales in the group) before and after the Existential-Humanistic group psychotherapy (based on a modified version of the semantic differential).

 

It should be noted that after the course of existential-humanistic group psychotherapy the patients continued to complain on head aches, mood swings, fatigue and lack of motivation for professional activity.

Analysis of the results obtained by using the Mini-Mult Test at the beginning and at the end of Existential-Humanistic psychotherapy. Since we analyze the dependent samples (up to 35 people) — before and after the course of group of psychotherapy sessions and psychopharmacological therapy — we chose a nonparametric criterion of signs as the main statistical method to compare two dependent samples based on the comparison of the number of positive and negative shifts of values. A non-parametric Wilcoxon test was chosen as an auxiliary method of mathematical analysis. As anull and working hypothesis of our experimental research, we accepted the following statements:

H0 — the differences between the scores of the Mini-Mult scales in the group of patients with diseases of the gastroenterological spectrum before and after a course of Existential-Humanistic psychotherapy are not significant.

H1 — the differences between the scores of the Mini-Mult scales in the group of patients with diseases of the gastroenterological spectrum before and after a course of Existential-Humanistic psychotherapy are statistically significant.

The differences were estimated between the indicators for each scale of the Mini-Mult Test. Since the nonparametric criteria allow us to estimate only one pair of variables characterizing the dependent groups for one analytical stage, the analysis results tables describe each pair separately.

The result of checking the significant differences between the indicators before and after the psychotherapeutic course according to the Mini-Mult Test showed that the reliable dynamics of the indexes was revealed on two scales — F (Reliability) and Hs (Hypochondria). For the remaining nine scales of this technique, the significant differences were not detected.

Hypothesis Test Summary

Asymptotic significances are displayed. The significance level is .05.
1 Exact significance is displayed for this test.

 

Figure 3. The resulting table of the reliable differences analysis of L-scale (Lie),
by the criterion of signs and Wilcoxon test, which support the null hypothesis.

 

In the table in Fig. 3, we estimate Sig.-index, which in both cases has a value that exceeds the maximum allowable significance level of 0.05. This gives us grounds for confirmation of the null hypothesis: the differences between the L-scores in the group of patients with diseases of the gastroenterological spectrum before and after a course of Existential-Humanistic psychotherapy are not significant.

The same conclusions can be applied to the following scales: Reliability (F), Depression (D), Hysteria (Hy), Psychopathy (Pd), Paranoid (Pa), Psychasthenia (Pt), Schizoid (Se) and Hypomania (Ma). The lack of significant differences in these scales confirms the stability of the individual characteristics of a person and the stability of the clinical condition, even in case of relatively long-term Existential-Humanistic psychotherapy.

Hypothesis Test Summary

Asymptotic significances are displayed. The significance level is .05.
1 Exact significance is displayed for this test.

 

Figure 4. The resulting table of the reliable differences analysis of F-scale (Reliability)
on the criterion of signs and Wilcoxon test which support the working hypothesis.

 

 

As can be seen from the Fig. 4—5 the Sig.-indicator value is below the acceptable level of significance of 0.05. This fact gives us grounds to confirm the statistical hypothesis, that the differences between the scores on the F (Aggravation) and Hs (Hypochondria) scales in the group of patients with diseases of the gastroenterological spectrum before and after the course of Existential-Humanistic psychotherapy are statistically significant.

Hypothesis Test Summary

Asymptotic significances are displayed. The significance level is .05.
1 Exact significance is displayed for this test.

 

Figure 5.The resulting table of the reliable differences analys is of Hs-scale (Hypochondria) on the criterion of signs and Wilcoxon test which support the working hypothesis.

 

After revealing the significant differences in Reliability (F) and Hypochondria (Hs) scales before and after the Existential-Humanistic psychotherapy, to disclose the nature of the changes in these scales, we have calculated the descriptive statistics: mean and standard deviation (Tables 1—2).

 

Table 1

The mean values of indicators of the Mini-Mult scales in the group of patients at the beginning of the group Existential-Humanistic psychotherapy

 

Assessing the minimum and maximum values on the scales, it can be argued that there are no emissions in the distribution of values with in data-dependent samples. The absence of emissions makes it statistically legitimate to assess the mean values in the future.

 

Table 2

The mean values of indicators of the Mini-Mult scales in the group of patients at the end of the group Existential-Humanistic psychotherapy

 

At the end of the group Existential-Humanistic psychotherapy, the average scores on the scales of Reliability and Hypochondria decreased. This fact indicates positive dynamics of the psycho-emotional state of patients.

For the purpose of more meaningful analysis of the differences, we derived two graphs (Fig. 6). Statistically significant differences between the scores in the group of patients before and after the course of psychotherapy were identified on two scales: Reliability (Aggravation) and Hypochondria. The changes in the Reliability scale among patients were manifested in the reduction of the tendency to hyperbolize the symptomatic characteristic of their physical state. Moreover, the desire to emphasize the severity of the physical state was leveled as a result of psychotherapy.

 

Figure 6. Dynamics of indicators on the Mini-Mult scales before and after
the Existential-Humanistic psychotherapy.

 

A predominance of the passive personal position, a high level of awareness of the existing problems through the prism of frustration and a pessimistic assessment of its prospects, the tendency to a negative perception of the world due to illness, inertness in a decision-making were noticed at the beginning of a group psychotherapy. But at the end of the group Existential-Humanistic psychotherapy the focus shifted towards positive understanding of the future prospects, new meanings of life, further actions aimed at restoring health and lifestyle changes.

The analysis of the dynamics of test results by the M. Lüscher Color Test and the Method of Portrait Elections by L. Szondi in the group of patients at the beginning and end of the Existential-Humanistic psychotherapy. As a result of meaningful interpretation of the vectors and factors of the Szondi Portrait Elections Test before and after psychotherapy, the following changes were found: the tendencies to outwardly aggressive response and selfishness have become less pronounced; the increased self-control and distrustfulness have also reduced after a course of psychotherapy.

The analysis of diagnostic results by the M. Lüscher Color Test, identified changes in the following characteristics: the frustration of the need for hope for the best and the anxiety have decreased; the desire for peace, rest, and also, the dissatisfaction with the attitude towards oneself remained unchanged; the negative attitude to the situation have leveled; the volitional qualities and the self-confidence have increased.

 

 

_______________________

* The authors would like to thank to Cand. Sc. (Psychology) Bogdan Bozhuk, Cand. Sc. (Psychology) Natalia Kucherovska, Cand. Sc. (Psychology) Liudmila Dziubko, Cand. Sc. (Psychology) Irina Koval, Cand. Sc. (Psychology) Svetlana Fedko, clinician Prof. Elena Haustova and Tatiana Levina for their support and cooperation. The authors are inbebted to Natalia Lopushanska for her assistance in statistical data processing. 

 

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For citation

Bondarenko A.F., Maksimenko K.S. Experimental study of person-centered psychotherapy effectiveness (based on sample with chronic gastrointestinal diseases). Part I. Med. psihol. Ross., 2017, vol. 9, no. 2(43), p. 8 [in Russian, in English]. Available at: http://mprj.ru 



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