Pretreatment expectations, interpersonal functioning, and symptoms in the prediction of the therapeutic alliance across supportive-expressive psychotherapy and cognitive therapy

Therapeutic alliance has been a robust predictor of therapy outcome, yet little is known about which patient variables predict the development of an alliance between patient and therapist in time-limited manualized therapies. The authors evaluated pretreatment predictors of therapeutic alliance, controlling for symptom change before its assessment, using a large sample of patients treated with either supportive-expressive (SE) dynamic psychotherapy or cognitive therapy. They found that SE patients with greater pretreatment expectations of improvement formed better alliances with their therapist at Session 2, and expectations significantly predicted alliance at Session 10 for both treatment groups. Further, patients in the SE condition demonstrated a significant relation between positive expectations and growth in alliance. Women achieved better alliances at Session 10. Finally, hostile-dominant interpersonal problems significantly predicted poor alliance. Pretreatment symptom level was not significantly predictive of alliance.     

The quest for connection in interpersonal and therapeutic relationships

Objective: This paper focuses on the need for connection as a common core theme at the heart of both close relationships and therapeutic relationships and explores ways to connect these two research domains that have evolved as separate fields of study. Bowlby's attachment theory provides a strong conceptual and empirical base for linking human bonds and bonds in psychotherapy. Method: The growing body of research intersecting attachment and psychotherapy (1980–2014) is documented, and meta-analytic studies on attachment–outcome and attachment–alliance links are highlighted. Results: Five ways of studying attachment as a variable in psychotherapy are underscored: as moderator, as mediator, as outcome, client–therapist attachment match, and as process. By integrating conceptualizations and methods in studying relational narratives of client–therapist dyads (Core Conflictual Relationship Theme), measures of alliance, and client attachment to therapist during psychotherapy, we may discover unique client–therapist relational dances. Conclusions: Future fine-grained studies on how to promote core authentic relational relearning are important to clinicians, supervisors and trainers, who all share the common quest to alleviate interpersonal distress and enhance wellbeing. Directions for advancing research on interpersonal and therapeutic relationships are suggested. Learning from each other, both researchers of close relationships and of psychotherapy relationships can gain a deeper and multidimensional understanding of complex relational processes and outcomes.     

Prediction of outcome of brief psychotherapy from therapist interpretive interventions

This study replicated Malan's 1976 analysis of psychodynamic interpretations and corrected the major methodological fault in his work: the use of therapist notes for rating the interpretive elements. In this study, the sessions of 25 patients treated in brief dynamic psychotherapy were audiotaped and the ratings of the interpretive interventions were made directly from the audiotapes. Malan's findings were supported. There was a positive association between more favorable outcome, measured on five psychodynamic scales, and the frequency with which therapist interpretations referred to emotions experienced in the transference relationship that were similar to those experienced in relationships with parents and other important persons. The results of this replication indicate that these therapist-offered explanations about the meanings of significant current and past interpersonal relationships contribute to the outcome of brief psychotherapy.     

Transference interpretations, therapeutic alliance, and outcome in short-term individual psychotherapy

Relationships between the proportion of transference interpretations provided by therapists and both therapeutic alliance and therapy outcome were investigated for a sample of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical trial investigation. Inverse relationships were found between the proportion of transference interpretations and both therapeutic alliance and favorable therapy outcome for patients with a history of high quality of object relations. An examination of individual sessions revealed evidence that was consistent with two different, but not mutually exclusive, causal explanations. The first concerned the negative effects of high proportions of transference interpretations; the second concerned the reaction of the therapist to the presence of a weak therapeutic alliance. While the evidence from our study was correlational, it was sufficiently strong to warrant alerting clinicians to the possibility of negative treatment effects when high levels of transference interpretations are used with certain types of patients receiving short-term individual psychotherapy.     

Symptom Level,Treatment Motivation,and the Effects of Inpatient Psychotherapy

Patients' motivational characteristics are of crucial importance for the effectiveness of inpatient psychotherapy. In the present study of 250 patients from a German psychotherapy ward, 4 dimensions of motivation for psychotherapy (negative illness consequences, psychosocial lay etiology, psychotherapeutic treatment expectations, openness to psychotherapy) were assessed using a questionnaire measure of psychotherapy motivation (Fragebogen zur Messung der Psychotherapiemotivation) and related to pre- and posttherapy changes in symptomatology. Psychological symptoms as well as interpersonal problems were considered indicators of treatment effects. Results support the expectation that a psychosocial causal attribution of illness symptoms and a marked general openness to psychotherapy at the pretreatment interview predict more positive treatment outcomes. In the subsample of patients with somatization/dissociative disorders low in openness, an increased risk of ineffective treatment was evident. Implications of the results of pretreatment interventions are discussed.     

Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol

Objective: In the past decade, variation in outcomes between therapists (i.e., therapist effects) have become increasingly recognized as an important factor in psychotherapy. Less is known, however, about what accounts for differences between therapists. The present study investigates the possibility that therapists' basic therapy-related interpersonal skills may impact outcomes. Method: To examine this, psychotherapy postgraduate trainees completed both an observer- and an expert-rated behavioral assessment: the Therapy-Related Interpersonal Behaviors (TRIB). TRIB scores were used to predict trainees' outcomes over the course of the subsequent five years. Results: Results indicate that trainees' with more positively rated interpersonal behaviors assessed in the observer-rated group format but not in a single expert-rated format showed superior outcomes over the five-year period. This effect remained controlling for therapist characteristics (therapist gender, theoretical orientation [cognitive behavioral or psychodynamic], amount of supervision, patient's order within therapist's caseload), and patient characteristics (patient age, gender, number of comorbid diagnoses, global severity, and personality disorder diagnosis). Conclusions: These findings underscore the importance of therapists' interpersonal skills as a predictor of outcome and source of therapist effects. The potential utility of assessing therapists' and therapists-in-training interpersonal skills are discussed.     

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems.     

Interpretation of transference in the psychotherapy of adolescents and young adults

There is considerable controversy in the literature surrounding the role of interpretation of transference in the expressive psychotherapy of adolescents and young adults. The authors contend that interpretation of transference is often underutilized in the psychotherapy of adolescents and that many treatments could be enriched by its inclusion. It is argued that interpretation of the transference in the immediate "here and now" of the therapeutic encounter should take precedence over genetic transference interpretation, which attempts to link current attitudes toward the therapist to archaic attitudes toward the parents. Six guidelines founded on a developmental perspective are described for exploring transference themes in this age group. While interpretation of transference is neither a panacea nor uniquely mutative with adolescents and young adults, the authors believe it has an important role to play in expressive psychotherapy if used judiciously and with foresight.     

Modulating effect of experience and theoretical-technical orientation on the personal style of the therapist

Abstract

Objective: This qualitative study systematically compared cases treated by the same therapist in order to understand the group comparison findings of a larger study on training of experienced therapists (the “Vanderbilt II” psychotherapy project). Method: The therapist, Dr C., was selected based on the therapist's overall treatment successes. His two patients were selected based on their outcomes and the relative training cohort from which they were drawn: a case with successful outcome from the pre-training cohort and a case of negligible improvement from the post-training cohort. Results: Dr C. demonstrated a variety of interpersonal skills throughout his pre-training case, though there was also poor interpersonal process throughout. However, in the second case he had considerable difficulty in adapting his typical therapeutic approach to the requirements of the time-limited dynamic psychotherapy (TLDP) manual, even while appearing to work hard to find ways to use the manual. Conclusions: Dr C.'s spontaneity, and his unique set of interpersonal skills may enhanced his initial rapport and alliance building with clients and yet may not have interfaced well with TLDP. His unique interpersonal skills also may have contributed to problems of interpersonal process. Future research may benefit from examining the interaction of between therapist interpersonal skills and the implementation of the treatment manual.     

Moderators of the effects of transference interpretations in brief dynamic psychotherapy

Abstract

The primary aim of this study is to measure effects of transference interpretations in brief dynamic psychotherapy using an experimental design. One hundred patients were randomized to dynamic psychotherapy over 1 year either with a moderate level of transference interpretations or without transference interpretations. The outcome measures were the Psychodynamic Functioning Scales, Inventory of Interpersonal Problems, Global Assessment of Functioning, and Symptom Checklist-90-Revised. No main effect of treatment was found. Several pretreatment patient characteristics related to interpersonal functioning and symptom severity were selected for exploratory analyses of moderator effects. Contrary to our hypotheses and mainstream clinical thinking, we found that patients with more interpersonal problems, more severe symptoms, or poorer quality of life responded better to therapy with transference interpretations than to therapy without such interpretations. Conversely, we found that more resourceful and less disturbed patients tended to have a negative response to transference interpretations.     

Relationships Between God and People in the Bible: A Core Conflictual Relationship Theme Study of the Pentateuch/Torah

Abstract

The most widely known images of God are from the Bible. An important characteristic of these images is their portrayal of God's interactions with people. Although there have been many religious and literary discussions of God's relationships with people in the Bible, no systematic psychological assessment has been reported. Therefore, the aim of this study was an innovation: to identify patterns of relationship between God and people portrayed in the first five books of the Bible, the Pentateuch or Torah, by using the core conflictual relationship theme (CCRT) method, a widely used scoring system for the assessment of interpersonal relationships. Reliability for the application of the CCRT method to relationship episode narratives in the Pentateuch/Torah was assessed and found to be very good. Results show that the most frequent theme in relationship episode narratives about God and people is that God is helpful. Two less frequent but also highly repetitive themes are that God controls or hurts the other person. Many differences were found between relationship themes defined by the type of person with whom God interacted: patriarch, Moses, woman, non-Israelite, or not a non-Israelite. Thus, the CCRT results identify several different patterns of relationship between God and people.     

Stressful involvement in psychotherapeutic work: Therapist, client and process correlates

Abstract We examined potential predictors of therapists' "Stressful Involvement" (SI) among variables reflecting the psychotherapy process, therapist characteristics, patients' symptom severity or context variables (treatment setting). Ninety-eight sequences from individual psychodynamic treatments conducted by 26 therapists were studied. Data were analyzed using mixed regression models. Between-therapist and within-therapist variance accounted for most of the difference in SI. SI was strongly associated with negative feelings of the therapist about patient and therapy in the time between sessions. Therapists with more 'unassertive' and 'vindictive' interpersonal styles were also more prone to experiencing SI. The strong association of SI with therapist rather than patient characteristics and process ratings indicates the importance of further study of the therapist as a person and participant in psychotherapy.     

Relationships between God and people in the Bible: a core conflictual relationship theme study of the Pentateuch/Torah

The most widely known images of God are from the Bible. An important characteristic of these images is their portrayal of God's interactions with people. Although there have been many religious and literary discussions of God's relationships with people in the Bible, no systematic psychological assessment has been reported. Therefore, the aim of this study was an innovation: to identify patterns of relationship between God and people portrayed in the first five books of the Bible, the Pentateuch or Torah, by using the core conflictual relationship theme (CCRT) method, a widely used scoring system for the assessment of interpersonal relationships. Reliability for the application of the CCRT method to relationship episode narratives in the Pentateuch/Torah was assessed and found to be very good. Results show that the most frequent theme in relationship episode narratives about God and people is that God is helpful. Two less frequent but also highly repetitive themes are that God controls or hurts the other person. Many differences were found between relationship themes defined by the type of person with whom God interacted: patriarch, Moses, woman, non-Israelite, or not a non-Israelite. Thus, the CCRT results identify several different patterns of relationship between God and people.     

Psychotherapie mit Älteren: Zielsetzungen, Möglichkeiten und Grenzen

Age should not be considered a detriment to entering into a therapeutic relationship as psychotherapy with those in the 60+ age group has been shown to be useful and yield successful long-term results. Beyond the therapeutic method used, working with seniors (or the elderly) demands additional generally achievable objectives. Specifically, those from the field of psychoanalytic theory employ treatment methods such as relaxation and creative processes which have been found to be helpful and well-received by seniors. Focused short-term therapy and group therapy are the dominant methods used with this age group. It is important to note that the pairing of a senior with a younger therapist may constellate particular emotional difficulties on the part of the therapist. In particular, the therapist needs to be aware of her/his own unfamiliarity with the patient's earlier life phases, as well as the therapists's fear of her/his own aging process and a reverse unconscious transference. However, chronological age in and of itself is not a contraindication for a successful psychotherapy.     

INFLUENCES OF PATIENTS’ AND THERAPISTS’ INTERPERSONAL PROBLEMS AND THERAPEUTIC ALLIANCE ON OUTCOME IN PSYCHOTHERAPY

Abstract

The aim of this study was to investigate the importance of therapists’ and patients’ interpersonal problems as well as the impact of the therapeutic alliance on symptomatic outcome in psychotherapy. Of interest were direct effects of interpersonal problems, represented through the dimensions of affiliation and control, as well as possible interaction effects between patient and therapist variables on outcome. Further hypotheses referred to therapist differences in the predictive impact of the therapeutic alliance for outcome. Outcome ratings of 1,513 psychotherapy inpatients treated by 31 psychodynamically oriented individual psychotherapists were studied. Therapists’ and patients’ interpersonal dispositions were assessed with the Inventory of Interpersonal Problems, and patients answered standardized outcome measures before and after therapy and retrospectively evaluated the therapeutic alliance at discharge. The results indicate that dominant patients profited better from their therapy and that therapists’ interpersonal disposition did not have a direct influence on outcome. The influence of the therapeutic alliance on outcome varied among the therapists. The general positive effect of therapeutic alliance on outcome was stronger for less affiliative therapists. Limitations of the study and implications of the results are discussed.     

“The Shoop Shoop Song”

In this paper I describe how I integrate the interpersonal psychoanalytic idea of transference–countertransference with the systems idea of couple's fit. I define the two constructs as I use them, including a redefinition of couple's fit. The redefinition includes both the similarity of a couple's fears and the complementarity of the partners' styles of coping with those fears. I also contrast this integrative approach with that of projective identification. Finally, I describe a countertransference enactment with a couple to show that discussing such enactments can offer great therapeutic leverage. After the discussion, the therapist may find the connections between how the two people in the couple relate to each other and how the therapist and couple related. Clinical vignettes illustrate these ideas.