A Novel CCRT Reliability Study: Reply to Zander et al.

A new study of the reliability of the Core Conflictual Relationship Theme (CCRT) method should be welcome. But this one's welcome is reduced by its limited generalizability, for several reasons.     

Different Reliabilities at the Episode Level and that of the Final CCRT—A Rejoinder to Luborsky and Diguer

The Core Conflictual Relationship Theme (CCRT) method is one of the most thoroughly elaborated instruments in the field of quantifying relationship diagnosis. Its development not only fills a gap for clinicians and researchers, but it also represents an important innovative process for putting psychodynamic formulations into operation (cf. Schauenburg & Cierpka, 1994). The purpose of our two studies has been to contribute toward promoting the use of the CCRT method by simplifying the preparation of the material (video rating).     

Brain activation during autobiographical relationship episode narratives: A core conflictual relationship theme approach

Abstract

The authors combined the core conflictual relationship theme (CCRT) method and functional magnetic resonance imaging (fMRI) to identify brain regions involved in recall of autobiographical relationship episodes, a key process in psychotherapy. Relationship narratives were obtained from healthy subjects and scored for CCRT relationship themes and emotion. Autobiographical personal and nonautobiographical control narratives were presented in a block-design fMRI experiment. Personal versus control narratives showed activations in anterior cingulate, precuneus, inferior and middle frontal gyri, and inferior parietal lobule. These are regions involved in autobiographical memory, theory of mind, self-referential processing, and emotion. In an exploratory analysis, higher CCRT scores correlated with increased brain activation in the left hippocampus, parahippocampal gyrus, and middle occipital gyrus. This suggests that brain systems subserving memory processes are more active when recalling relationship episodes with greater CCRT content.     

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.     

Countertransference in the treatment of adolescents and its manifestation in the therapist-patient relationship

Abstract

Countertransference is a central construct in the clinical literature (Freud, 1910; Gabbard, 2001), yet it has generated very little research to date. The present study used the CCRT method (Luborsky & Crits- Cristoph, 1998) to measure countertransference themes in a sample of 12 therapists, who described relationship episodes with their parents and with two clients. Results showed high repetitiveness of the parent themes in the narratives about the patients for all three components of the CCRT: Wish, Response of Other and Response of Self. A qualitative analysis of the narratives generated four countertransference dynamics: Repeating the parent RO, repairing the parent RO, identification with the patient, and withdrawing. It is suggested that these four dynamics constitute the process which links the origins and triggers with the manifestations and effects in Hayes's (2004) operational model of countertranference.     

Therapists’ projection: The effects of therapists’ relationship themes on their formulation of clients’ relationship episodes

Abstract

In this analogue study, therapists identified the core conflictual relationship themes (CCRT; wishes, responses of others, and responses of self) in relationship episodes taken from multiple clients in Luborsky and Crits-Christoph (1998). Judges identified the therapists’ own CCRT using the Relationship Anecdotes Paradigm (Luborsky, 1990 Luborsky, L., Barber, J. P., Schaffler, P. and Cacciola, J. 1990. “The narratives told during psychotherapy and the types of CCRTs within them”. In Understanding transference: The CCRT method, Edited by: Luborsky, L. and Crits-Christoph, P. 117–132. New York: Basic Books.  [Google Scholar]). Profile similarity analysis was used to examine the relationship between therapists’ CCRT and the CCRT that they identified. Projection was identified by a significant relationship between the therapists’ own CCRT pattern and the CCRT pattern that they rated in relationship episodes from Luborsky and Crits-Christoph, especially for wishes. The therapists’ tendency to project was moderated by therapeutic experience and receipt of personal therapy.     

Relational schemas as mediators of innovative moments in symptom improvement in major depression

Objectives: Innovative moments (IMs) are exceptions to the maladaptive framework of meaning that typically motivates clients to seek psychotherapy, and previous studies have shown that IMs are associated with psychotherapy outcomes. While IMs are exceptions that occur at the level of the therapeutic conversation, relational schemas are more stable patterns, and their increased flexibility may facilitate change during psychotherapy. With this in mind, we tested the hypothesis that IMs contribute to outcomes by improving the flexibility of relational schemas. Method: The Core Conflictual Relationship Theme (CCRT) was used to assess relational schemas. IMs were evaluated using the Innovative Moments Coding System. The sample included 22 clients diagnosed with major depressive disorder. The flexibility of the three components of the CCRT (Wishes, responses of the self (RS), and responses of others (RO)) were tested as mediators between IMs and outcomes. Results: The flexibility of the RS was a mediator between IMs and outcomes, but Wishes and RO were not. Conclusion: These findings align with previous research showing that RS is the component most open to change, whereas the other components seem less sensitive to change during brief therapy.     

Common and Special Factors in Different Transference-Related Measures

This paper discusses the essence of what is in common among these seven transference-related measures. They all turn out to be moderately similar. The most similar of all are the CRPF, the SASB-CMP, the CCRT, and the FRAME methods. Their primary clinical applications are: to help in deriving reliable formulations, in focusing on transference-related congruent treatment interventions and in locating the conflicts associated with recurrent symptoms.     

Relationship representations and change in adolescents and emerging adults during psychodynamic psychotherapy

Objective: Two groups of clients at sequential developmental stages, adolescents and emerging adults, were compared regarding their presenting problems, psychological distress, and relationship representations over one year of psychotherapy. Method: Thirty adolescents aged 14–18 years and 30 emerging adults aged 22–28 years, with similar demographic background, completed outcome measures and interviews according to the Core Conflictual Relationship Theme (CCRT) method. Results: The groups differed significantly in the presenting problems but did not differ in their initial levels of distress; their symptoms improved to a similar extent after one year of psychotherapy; differences between the groups in the representations of others were consistent with age-specific developmental challenges; levels of representations were associated with levels of symptoms at the end-point of treatment. Conclusion: Clinicians need to be attuned to the specific difficulties and challenges of these continuous yet distinct developmental stages.     

An in-session exploration of ruptures in working alliance and their associations with clients’ core conflictual relationship themes,alliance-related discourse,and clients’ postsession evaluations

Abstract

This exploratory study examined (a) the relationship among the occurrence of ruptures in the working alliance, the emergence of client's core conflictual relationship themes (CCRT), and focus of discourse within therapeutic sessions and (b) the relationship between ruptures in the working alliance and client's postsession evaluations of session's smoothness and depth. The authors included 151 sessions from five therapies conducted in a student counseling center. Sessions were content analyzed by independent raters, and a self-report questionnaire was given to clients after each session. Ruptures were positively related to the emergence of clients’ CCRT during the session, but only when the therapist was addressed as the “other.” Sessions with ruptures were characterized by heightened discussion of working alliance components and were evaluated as less smooth than sessions without ruptures. Findings are discussed, and the importance of ruptures in working alliance for therapeutic change is emphasized.     

The association between total lymphocyte count after concomitant chemoradiation and overall survival in patients with newly diagnosed glioblastoma

Several studies have been conducted to determine the relationship between post-treatment total lymphocyte count (TLC) and overall survival (OS) in patients with malignant tumors including glioblastomas (GBMs). In this retrospective study, whether patients with newly diagnosed GBM experience significant lymphopenia after concomitant chemoradiation (CCRT) was evaluated, and whether TLC after this treatment is associated with OS in the treated population was examined. Using electronic medical records, all patients newly diagnosed with GBM between 2008 and 2016 at Seoul St. Mary’s Hospital were retrospectively examined. The eligible criteria included the following: 1) craniotomy with surgical resection or biopsy, 2) completion of CCRT, 3) accessible baseline and/or follow-up complete blood count (CBC). Median TLC significantly decreased after completion of CCRT, compared to TLC at baseline (1742 versus 1319 cells/mm³, P-value < 0.001). Patients with TLC < 1200 cells/mm³ at 4 weeks after the completion of CCRT showed shorter survival than those with TLC ≥ 1200 cells/mm³ with median OS of 14.5 versus 21.0 months (P-value = 0.017). Also, in multivariate analysis for OS, TLC < 1200 cells/mm³ at 4 weeks after the completion of CCRT (HR 1.97, 95% CI 1.61 – 2.25, P-value = 0.004) were significantly associated with shorter survival. The results from the present study indicate that treatment-related total lymphocyte counts after CCRT is associated with worse survival in patients with newly diagnosed GBM.     

Changes in interpersonal conflicts among adolescents during psychodynamic therapy

Abstract

The core conflictual relationship theme (CCRT) method was used in psychodynamic therapy with 10 adolescents to study change in interpersonal conflicts in the course of treatment. Relationship anecdote paradigm interviews were conducted at the beginning of therapy and before termination 8 to 9 months later. Adolescents were asked to describe 4 relationship episodes for each of the following significant others: parents, peers, and therapist. The CCRTs for the 3 relationships were different: The main wishes toward the parents were to be close and to be given independence; toward friends, to be close and to be open; and toward the therapist, to be helped and to be understood. The responses of other and self toward parents were significantly more negative than responses in other relationships. Responses of self and other in the therapeutic relationship were significantly more positive. At the end of therapy the interactions with parents were more positive, whereas those with the therapist grew more ambivalent.     

Temozolomide during and after Radiotherapy for Newly Diagnosed Glioblastomas : A Prospective Multicenter Study of Korean Patients

Objective

This study was performed to determine the safety and outcome of concurrent chemoradiotherapy (CCRT) and adjuvant chemotherapy with temozolomide for Korean patients with a newly diagnosed glioblastoma.

Methods

Patients were recruited from four institutions between 2004 and 2007. The patients received fractionated focal irradiation in daily fractions of 2 Gy given 5 days per week for 6 weeks and daily temozolomide, followed by 6 cycles of adjuvant temozolomide. The primary endpoint was overall survival (OS) and the secondary endpoints were progression-free survival (PFS), response, and safety.

Results

A total of 103 patients were enrolled in this study. Ninety-six patients (93%) completed the CCRT and 54 patients (52%) received 6 cycles of adjuvant temozolomide. The response rate was 73% (53/73) and the tumor control rate was 92% (67/73). Of the 96 patients who completed the CCRT, the median OS was 18.0 months and the 1- and 2-year OS rates were 74 and 38%, respectively. The median PFS was 10.0 months and the 1- and 2-year PFS rates were 33 and 16%, respectively. The only significant prognostic factor of survival was the extent of surgical resection (p<0.05). CCRT resulted in grade 3 or 4 hematologic toxic effects in 8% of patients. No opportunistic infections were noted.

Conclusion

This study is the first prospective multi-institutional report of CCRT and adjuvant chemotherapy with temozolomide for patients with a newly diagnosed glioblastoma in Korea. The current protocol may prolong the survival of Korean patients with a glioblastoma and may be tolerable in terms of toxicity.     

Differentiation in Self- and Object-Perception as a Goal in Psychodynamic Short-Term Therapy: A Cluster-Analytical Evaluation

In this paper, the question is examined as to how object relationship patterns can be adequately recorded and evaluated in the therapy process. Based on the consideration that the differentiation of object perception and its relationship patterns is a goal of psychodynamic therapy, a method for measuring repetitive interaction patterns is presented as an indicator of change. An approach based on cluster analysis offers the opportunity to record and evaluate the entire structure of a therapy without taking individual qualitative features out of their context to one another and to the specific object. The therapy records of a 3-month inpatient psychotherapy were evaluated with a content analysis, using the Structural Analysis of Social Behavior (SASB). The results of the cluster-analytical evaluation of this content analysis provide convincing evidence that the structure of the described object relationships can be recorded, and their transformation processes can be demonstrated with this process in the course of the therapy. In dieser Arbeit der frage nachgegangen, wie sich Objek-Beziehungsmuster im Therapieprozeß adäquat erfassen lassen. Ausgehend von der Überlegung, daß die Differenzierung der Objektwahrnehmung und deren Beziehungsgestaltungals ein Ziel Psycholdynamischer Therapie gilt, wire eine methode zur Messung repetitiver Interaktionsmuster als ein Indiakatorvon Veraenderung vorgestellt. Ein clusteranalytisches Vorgehen bietet die Moglichkeit, die Gesamtstruktur einer Therapie zu erfassen, ohne einzelne qualitative Merkmale aus ihrem kontext zueinander und zum spezifizchen Objekt zu reißen. Die Therapiprotokolle einer dreimonatigen stationären Psychotherapie wurden inhaltsanalytisch mit Hilfe der «Structural Analysis of Social Behavior» (SASB) ausgewertet. Die ergebnisse der clusternanlytischen Auswertung dieser Inhaltsanalyse belegen überzeugend, daß die Struktur der Geschilderten Objektbeziehungen erfaßt und deren Transformationsprozess im Verlauf der Therapie mit diesem Vorgehen aufgezeigt werden Können. Cette étude naturaliste examine la relation entre des patterns interpersonnels de base mesurés par la méthode du Thème Relationnel Conflictuel Central (CCRT) et la psychopathologie chez 55 patients sélectionnés pour une psychothérapie psychodynamique de longue durée. La psychopathologie a été évaluée selon DSM-III-R, par un auto-questionnaire de symptômes et par le Karolinska Profiles Psychodynamiqeu (KAPP). Les patients avec des diagnostics DSM-III-R différents n'ont pas montré de defférence dans leur CCRT obtenu sur la base d'interviews RAP (Paradigme d'anecdotes Relationnelles). par ailleurs, le manque de flexibilité («Pervsiveness») dans l'emploi des différentescomposantes du CCRT n'a pas été associé à des symptômes psychiatriques. Une seule corrélation significative entre pathologe de caractère et CCRT a été trouvée; une expérience de position sociale problématique a été associée des réponses de l'autre plus négatives. Nous discutons des limitations de la méthode du CCRT et de l'échantillon. En este trabajo se examina el problema de cómo registrar y evaluar adecuadamente en el proceso terapéutico las pauts de relación objetal. Como Indicador de cambio, se presenta un método para medir las pautas de interacción repetitivas que se apoya en la consideración de que un objetivo de la terapia psicodinámica es discriminar el objeto de la percepción y sus pautas relacionales. El enforque basado en el análisis de cluster ofrece la oportunidad de registrar y evaluar la estructura total de una terapia sin sacar los rasgos cualitativos individuales fuera de su contexto de relación recíproca o con el objeto específico. Se evaluaron los registors de una psicoterapia durante sus 3 meses de internación con un análisis de contenido, usando elanálisis Estructural del Comportamiento Social (SASB). Los resultados de la evaluació de este análisis dan evidencia de que la estructura de las relaciones objetales descritas son pasibles de registro y de que enel curso de la terapia pueden demostrarse sus procesos de transformación.     

Reformulation of the Core Conflictual Relationship Theme (CCRT) Categories: The CCRT-LU Category System

The Core Conflictual Relationship Theme (CCRT) method, developed by Lester Luborsky, is regarded as an established technique for assessing central relationship patterns in psychotherapy research. Numerous studies have investigated associated research areas and clinical applications. Many of these studies have reported problems with the CCRT method attributable to the underlying construct of the CCRT categories. This study describes the development of alternative German CCRT categories, the CCRT-LU categories, in which LU stands for the place of development (Leipzig/Ulm) and for the ‘logically unified’ aspect of the system. For the 1st time, the CCRT-LU categories are assigned to a sample of clinical intake interviews with 32 female patients.