Assimilation and the process of outcome: Introduction to a special section

Abstract

The current study investigated the extent to which outpatient psychotherapy clients benefited from Pennebaker's expressive writing protocol (Pennebaker &; Beall, 1986) adapted for use as a homework intervention. Participants were randomly assigned to written emotional disclosure or writing control conditions. Pre- and postintervention outcome measures were collected for three consecutive therapy sessions. Clients in the written emotional disclosure group showed significantly greater reductions in anxiety and depressive symptoms as well as greater overall progress in psychotherapy in comparison to the writing control group. Results suggest that emotional disclosure writing homework, in conjunction with outpatient psychotherapy, facilitates therapeutic process and outcome.     

Goldilocks on the couch: Moderate levels of psychodynamic and process-experiential technique predict outcome in psychodynamic therapy

Objectives: Greater symptom change is often assumed to follow greater technique use, a “more is better” approach. We tested whether psychodynamic techniques, as well as common factors and techniques from other orientations, had a curvilinear relation to outcome (i.e., whether moderate or “just right” intervention levels predict better outcome than lower or higher levels). Methods: For 33 patients receiving supportive-expressive psychodynamic psychotherapy for depression, interventions were assessed at Week 4 using the multitheoretical list of therapeutic interventions and symptoms were rated with the Hamilton Rating Scale for Depression. Results: Moderate psychodynamic and experiential techniques predicted greater symptom change compared to lower or higher levels. Conclusion: This “Goldilocks effect” suggests a more complex relation of intervention use to outcome might exist.     

Therapist interventions using the Psychodynamic Interventions Rating Scale (PIRS) in dynamic therapy,psychoanalysis and CBT

Abstract

One requirement for psychotherapy research is an accurate assessment of therapeutic interventions across studies. This study compared frequency and depth of therapist interventions from a dynamic perspective across four studies, conducted in four countries, including three treatment arms of psychodynamic psychotherapy, and one each of psychoanalysis and CBT. All studies used the Psychodynamic Intervention Rating Scales (PIRS) to identify 10 interventions from transcribed whole sessions early and later in treatment. The PIRS adequately categorized all interventions, except in CBT (only 91–93% categorized). As hypothesized, interpretations were present in all dynamic therapies and relatively absent in CBT. Proportions of interpretations increased over time. Defense interpretations were more common than transference interpretations, which were most prevalent in psychoanalysis. Depth of interpretations also increased over time. These data can serve as norms for measuring where on the supportive-interpretive continuum a dynamic treatment lies, as well as identify potentially mutative interventions for further process and outcome study.     

Changing character: A narrative review of personality change in psychotherapies for personality disorder

Objective: Personality disorder (PD) is a negative prognostic indicator for treatment, and absolute improvements in functioning among these patients are often modest. This may be because personality features that give rise to dysfunction in PD are not targeted optimally during most treatments. Method: Attachment, mentalization, core beliefs, and personality organization/defense use were identified as personality constructs that have been pursued in treatment studies and that are proposed to underlie PD. Results: All constructs correlate with psychiatric symptoms, PD diagnosis, and functioning. Defense mechanisms and core beliefs further distinguish specific PDs, whereas personality organization separates more versus less severe PDs. Evidence from treatment and naturalistic studies indicate that maturation of defense mechanisms temporally precedes improvements in symptoms and functioning. Changes in attachment and mentalization correlate with some outcomes, but mediation of improvement has not been established. In psychodynamic therapy, transference interpretations may promote amelioration of personality dysfunction. With the exception of attachment, the experimental literature is lacking that could explicate the mechanisms by which these personality constructs maintain psychosocial dysfunction. Conclusions: Future research should aim to identify changes in these mechanisms that mediate positive outcomes in PD, as well as the specific therapeutic procedures that best promote positive change in PD.     

Linguistic measures of the referential process in psychodynamic treatment: The English and Italian versions

Abstract

The referential process is defined in the context of Bucci's multiple code theory as the process by which nonverbal experience is connected to language. The English computerized measures of the referential process, which have been applied in psychotherapy research, include the Weighted Referential Activity Dictionary (WRAD), and measures of Reflection, Affect and Disfluency. This paper presents the development of the Italian version of the IWRAD by modeling Italian texts scored by judges, and shows the application of the IWRAD and other Italian measures in three psychodynamic treatments evaluated for personality change using the Shedler-Westen Assessment Procedure (SWAP-200). Clinical predictions based on applications of the English measures were supported.     

Transference,countertransference, emotional expression,and session quality over the course of supportive expressive therapy: The raters' perspective

Abstract

Independent judges rated transference, countertransference, therapist emotional expression, and session quality, in videotaped sessions of Supportive Expressive Psychotherapy for Depression over time. Based on 44 patients and four therapists, HLM analyses suggested that negative transference predicted therapist expression of negative affect. While negative transference predicted a rough session, positive transference predicted a deep session. Positive countertransference and positive affect predicted a smooth but superficial session, with positive transference sometimes acting as a moderator. Sessions became less deep and smoother over time, with therapist emotional expression moderating the relationship between treatment phase and depth. The results suggest that positive countertransference behaviors and feelings have a particularly negative impact on a session and that transference contributes to a deep and rough session.     

The process of change in brief psychotherapy: Effects of psychodynamic and cognitive–behavioral prototypes

Abstract

A brief psychodynamic psychotherapy was assessed using the Brazilian Portuguese version of the Psychotherapy Process Q-Set (PQS). Each session was scored for its adherence to expert psychodynamic therapy (PDT) and cognitive–behavioral therapy (CBT) prototypes derived from the PQS. Results revealed that the therapy process adhered more closely to prototypical CBT than prototypical PDT. Bivariate time-series analyses showed that prototype components capturing the client's adherence to ideal CBT behaviors and collaboration between therapist and client on ideal PDT and CBT behaviors predicted therapy progress. In addition, specific client symptoms influenced whether the therapist adhered to prototypical PDT or CBT behaviors.     

How do patients with anorexia nervosa “process” psychotherapy between sessions? A comparison of cognitive–behavioral and psychodynamic interventions

Objective: Patients’ processing of psychotherapy between sessions (“inter-session process” (ISP)) has been repeatedly shown to be related to outcome. The aim of this study was to compare ISP characteristics of cognitive–behavioral vs. psychodynamic psychotherapy in the treatment of anorexia nervosa (AN) and their relation to outcome. Methods: Data of 106 patients participating in a randomized-controlled trial who received either 40 sessions of enhanced cognitive–behavioral therapy (CBT-E) or focal psychodynamic therapy (FPT) were analyzed. The ISP was measured with the Inter-session Experience Questionnaire (IEQ). Three outcome classes were distinguished: full recovery, partial recovery, and still fulfilling all AN criteria. Results: Patients receiving CBT-E reported more on “applying therapy” in the initial and the final treatment phase compared to FPT patients. In terms of process–outcome relations, higher levels of “recreating the therapeutic dialogue between sessions,” “recreating the therapeutic dialogue with negative emotions” as well as “applying therapy with negative emotions” in the final phase of treatment predicted negative outcome in FPT, whereas overall higher levels of negative emotions predicted negative outcome in CBT-E. Conclusions: In outpatient treatment in AN, the processing of therapy as measured by the IEQ showed surprisingly few differences between CBT-E and FPT. However, different ISP patterns were predictive of outcome, pointing to different mechanisms of change.     

The Scales of Psychological Capacities: Adaptation to an adolescent population

Abstract

Given the dearth of pediatric outcome measures, Wallerstein's “Scales of Psychological Capacities” (SPC), measuring psychotherapy changes with adults and reflecting shifts in character without specific adherence to a school of personality, was adapted to adolescents (Ad-SPC) and examined psychometrically. Twelve child psychoanalysts were consulted for content validity. Two investigators determined it to have high face validity after administering it to 40 adolescents. High inter-rater reliability was achieved for individual scale items. Construct validity was determined using Pearson correlations between multiple Ad-SPC items and co-administered validated measures of psychopathology. Preliminary psychometric properties support the Ad-SPC's potential for applicability in adolescent psychotherapy.     

20/20 Hindsight: A 25-year programme at the Anna Freud Centre of efficacy and effectiveness research on child psychoanalytic psychotherapy

Objective: This paper describes the evolution of methods of enquiry—through 25 years of work, with Professor Peter Fonagy and many other colleagues—of research and theorizing about child and adolescent therapy outcomes. Method: The work has focused on measuring psychoanalytic outcomes, but with an increasing interest in discovering therapeutic elements across treatment modalities. Results: Headline findings are described, with lessons from the ups and downs of developing (a) retrospective, follow-up, and prospective outcome studies, and (b) measures of child and family functioning. Issues of manualizing and measuring treatment process are discussed, together with the fruitfulness of mixed-method (quantitative and qualitative) process and outcome research with young people and families. Conclusions: Using the dilemmas, experiences, and findings ??of our group as examples, growing points and well as growing pains for the field are suggested.     

Therapist immediacy: The association with working alliance,real relationship,session quality,and time in psychotherapy

Objective: This longitudinal analysis examined the relationship between amount of therapist immediacy in sessions and client post-session ratings of working alliance (WAI), real relationship (RRI), and session quality (SES). Method: Using hierarchal linear modeling (HLM), we disaggregated the variables into within-client (differences between sessions in immediacy) and between-clients (differences between clients in immediacy) components, in order to test associations over time in treatment. Three hundred and sixty four sessions were nested within 16 clients and 9 therapists. Results: When therapists used more immediacy in a session, clients gave higher SES ratings for that session, compared to their sessions with less immediacy (within-client effect). For WAI, it appeared to matter when immediacy was used in treatment. The interaction effect between time in treatment and within-client immediacy revealed that early in treatment, more immediacy in a session was related to lower WAI for that session, whereas later in treatment, more immediacy in a session was related to higher WAI for that session. Another interaction effect was found between time in treatment and between-clients immediacy. Clients with less immediacy in treatment, gave higher SES scores for early sessions, than clients with more immediacy in treatment. Conclusions: Immediacy has an overall positive effect on session quality, but the time in which it is used in treatment and client characteristics should be taken into account both in practice and research.     

Mind the gap: In-session silences are associated with client attachment insecurity,therapeutic alliance,and treatment outcome

Objective: The association between in-session silences and client attachment, therapeutic alliance, and treatment outcome was investigated in two treatments for bulimia nervosa. Method: 69 women and one man were randomized to two years of psychoanalytic psychotherapy (PPT) or 20 sessions of cognitive behavioral therapy (CBT). Client attachment was assessed using the Adult Attachment Interview. Early, middle and late sessions (N?=?175) were evaluated with the Vanderbilt Therapeutic Alliance Scales, and quality of in-session silences was coded with the Pausing Inventory Categorization System (PICS). Multilevel Poisson and linear regression analyses were performed. Results: Coders identified 6236 pauses, which were more frequent in PPT than in CBT. Higher pausing frequency and higher relative frequency of obstructive pauses were associated with client insecure attachment as well as with poorer treatment alliance, and accounted for part of the relation between client attachment and therapeutic alliance. Good outcome clients had higher relative frequency of productive pauses, especially in mid-treatment, and lower relative frequency of obstructive pauses, especially in late treatment. Conclusion: The study further validates the PICS. Findings indicate that therapists may be able to use in-session silences as an indicator of client attachment insecurity and as a prognostic sign of eventual treatment outcome.     

Effects of providing domain specific progress monitoring and feedback to therapists and patients on outcome

Objective: Progress monitoring and feedback reduces the number of patients deteriorating in psychotherapy. The current study examined the effects of providing treatment progress information to therapists and patients using individual feedback of both wellbeing and affective psychological distress compared to feedback of wellbeing alone. Method: The sample comprised 845 consecutive psychiatric day-hospital admissions using a historical cohort design. The effects of monitoring and feedback of wellbeing in Cohort 1 were compared against the effects of monitoring and feedback of both wellbeing and affective psychological distress in Cohort 2. Results: Patients who were “not-on-track” in Cohort 2 demonstrated significantly greater improvement for affective psychological distress than those from Cohort 1. Conclusions: These findings suggest that providing feedback from multiple sources enhances patient outcomes in comparison to single source feedback.     

Patient affect experiencing following therapist interventions in short-term dynamic psychotherapy

Abstract

The aim of this research was to examine the relationship between therapist interventions and patient affect responses in Short-Term Dynamic Psychotherapy (STDP). The Affect Experiencing subscale from the Achievement of Therapeutic Objectives Scale (ATOS) was adapted to measure individual immediate affect experiencing (I-AES) responses in relation to therapist interventions coded within the preceding speaking turn, using the Psychotherapy Interaction Coding (PIC) system. A hierarchical linear modelling procedure was used to assess the change in affect experiencing and the relationship between affect experiencing and therapist interventions within and across segments of therapy. Process data was taken from six STDP cases; in total 24 hours of video-taped sessions were examined. Therapist interventions were found to account for a statistically significant amount of variance in immediate affect experiencing. Higher levels of immediate affect experiencing followed the therapist's use of Confrontation, Clarification and Support compared to Questions, Self-disclosure and Information interventions. Therapist Confrontation interventions that attempted to direct pressure towards either the visceral experience of affect or a patient's defences against feelings led to the highest levels of immediate affect experiencing. The type of therapist intervention accounts for a small but significant amount of the variation observed in a patient's immediate emotional arousal. Empirical findings support clinical theory in STDP that suggests strategic verbal responses promote the achievement of this specific therapeutic objective.     

Use of the Adult Attachment Interview to measure process and change in psychotherapy

Abstract

The Adult Attachment Interview (AAI), developed and extensively tested in the domain of developmental psychology, has relevance to psychotherapy research. The authors compare and contrast the ways that social psychologists and developmental psychologists have operationalized the concept of attachment security and discuss corresponding implications for psychotherapy research. In addition, they provide an overview of the AAI and its development, reliability, and validation in developmental psychology and summarize recent work linking AAI responses with distinctive types of psychopathology. A summary of recent work showing the AAI to be a useful indicator of positive outcome in psychotherapy for adults with diverse problems, including depression, borderline personality disorder, and posttraumatic stress disorder, is provided.     

“If those tears could talk,what would they say?” Multi-method analysis of a corrective experience in brief dynamic therapy†

We analyzed master theorist/therapist Hanna Levenson’s six-session work with “Ann” in American Psychological Association’s Theories of Psychotherapy video series to determine if and how this client had a corrective experience in Brief Dynamic Therapy. First, we identified indicators of a corrective experience in the therapist’s and client’s own words. Complementing this analysis, we used observational coding to identify, moment by moment, narrative-emotion markers of shifts in Ann’s “same old story”; the frequency, type, and depth of immediacy; and the client’s and therapist’s behavioral contributions to the working alliance. Additionally, we qualitatively analyzed Levenson’s session-by-session accounts of the therapy from two sources. Convergent evidence from these multi-method analyses suggested how the intertwined relational and technical change processes seemed to bring about this client’s corrective experience. Through consistent attention to the alliance and increasingly deep immediacy, Levenson created a safe space for Ann to “bring down the wall”—by allowing herself to cry and be deeply understood and cared for in a way that she had never before experienced. Concurrently, Ann began seeing herself quite differently, signified by self-identity narrative change. Then, following Session 4, she took Levenson’s suggestion to risk behaving more authentically with a friend and with her romantic partner.     

Self-Image as a Moderator of Change in Psychotherapy1 Margrethe S. Halvorsen and Jon T. Monsen,Department of Psychology,University of Oslo,Oslo, Norway.

Abstract

This study used the Structural Analysis of Social Behavior (SASB) introject model to investigate the relationship between patients’ self-image at pretreatment and change during psychotherapy. Data were obtained from the Norwegian Multisite Study of Process and Outcome in Psychotherapy, including 233 completed therapies. The patients were classified into four self-image profile groups (i.e., self-attack, self-control, intermediate attack–control, and self-love) based on their initial SASB pattern coefficients. Overall, the results indicated that response to treatment was contingent on self-image at pretreatment. Patients with a self-attacking self-image showed larger reductions in symptoms and sum criteria on Axis II during psychotherapy than those with less pathological self-images. As expected, the primary change in self-image was along the affiliation dimension, although patients with elevated pretreatment levels of self-control revealed substantial changes along the interdependence dimension as well.     

Psychotherapy expertise in Singapore: A qualitative investigation

Abstract

Personal characteristics, developmental influences, and therapy practices of nine peer-nominated expert psychotherapists practicing in the diverse country of Singapore were identified using qualitative methods. Sixteen themes were organized within four categories: (a) personal characteristics (empathic, nonjudgmental, respectful); (b) developmental influences (experience, self-awareness, humility, self-doubt); (c) approach to practice (balance between support and challenge, flexible therapeutic stance, empowerment/strength-based approach, primacy of the therapeutic alliance, comfortable addressing spirituality, embraces working within a multicultural context); and (d) ongoing professional growth (professional development practices, benefits of teaching/training others, challenges to professional development in Singapore). Cross-cultural comparisons between this study and Jennings and Skovholt's (1999) study of Minnesota expert psychotherapists found considerable overlap of themes. Implications for research and practice of psychotherapy are offered.     

The Mechanisms of Sudden Gains in Supportive–Expressive Therapy for Depression

Abstract

A sudden gain is a large symptom improvement in one between-session interval. Studies of cognitive–behavioral therapy (CBT) reported that many more cognitive changes occurred in pregain sessions (sessions immediately preceding sudden gains) than in control sessions. This study investigated sudden gains in supportive–expressive therapy (SE) for depression. Compared with control sessions, in these SE pregain sessions the authors found significantly greater therapist interpretation accuracy, better therapeutic alliance at a trend level, but an almost identical number of cognitive changes. Results from this SE study and past CBT studies suggest that sudden gains in different treatments may be associated with different mechanism factors: cognitive changes in CBT and accurate interpretations and possibly therapeutic alliance in SE.

Zusammenfassung

Die Mechanismen plötzlicher Gewinne in unterstützend-expressiver Therapie bei Depression

Ein plötzlicher Gewinn ist eine Symptomverbesserung in einem Intervall zwischen zwei Sitzungen. In Untersuchungen zu kognitiv-verhaltensmäßiger Therapie (cognitive-behavioral therapy, CBT) wurde berichtet, dass viel mehr kognitive Veränderungen in Sitzungen vor dem Gewinn (Sitzungen, die direkt dem plötzlichen Gewinn vorausgehen) als in Kontrollsitzungen auftreten. Diese Studie untersuchte plötzliche Gewinne in unterstützend-expressiver Therapie (supportive-expressive therapy, SE) bei Depression. Bei Vergleichen mit Kontrollsitzungen fanden die Autoren für Sitzungen vor dem Gewinn eine signifikant größere Interpretationsgenauigkeit der Therapeuten und eine dem Trend nach bessere therapeutische Allianz, aber eine fast identische Anzahl von kognitiven Veränderungen. Die Ergebnisse dieser SE Untersuchung und die früheren CBT Studien legen nahe, dass plötzliche Gewinne in verschiedenen Behandlungen mit verschiedenen Mechanismen verbunden sein könnten: Kognitive Veränderungen bei CBT und genauere Interpretationen und möglicherweise eine größere therapeutische Allianz bei SE.

Résumé

Les mécanismes de gain soudain dans la thérapie supportive–expressive de la dépression

Un gain soudain est une amélioration symptomatique importante au cours d'un intervalle entre deux séances. Des études de thérapie cognitivo-comportementale (CBT) ont montré que beaucoup plus de changements ont lieu dans les séances pré-gains (les séances qui précèdent immédiatement les gains soudains) que dans des séances contrôles. Cette étude a examiné des gains soudains dans la thérapie supportive–expressive (SE) de la dépression. En comparaison avec les séances de contrôle, les auteurs ont trouvé dans ces séances SE pré-gains une précision des interprétations thérapeutiques significativement plus haute, une meilleure alliance thérapeutique au niveau d'une tendance, mais un nombre presque identique de changements cognitifs. Les résultats de cette étude SE et des études de CBT du passé suggèrent que des gains soudains dans des traitements différents peuvent être associés avec des facteurs de mécanisme différents?: des changements cognitifs en CBT et des interprétations précises et peut-être l'alliance thérapeutique en SE.

Resumen

Mecanismos de mejorÍa sÚbita en la terapia de apoyo_expresiva para la depresión

Una ganancia súbita es un síntoma importante de mejoría en un intervalo de 1 sesión. Los estudios de terapia cognitivo-comportamental (CBT) mostraron que ocurrieron muchos más cambios cognitivos en sesiones previas (pregain sessions) (sesines que precedieron en forma inmediata a las ganancias súbitas) que en sesiones de control. Este estudio investigó ganancias súbitas en terapia de spoyo-expresiva (SE) para la depresión. Comparando estas sesiones con las de control, los autores encontraron una mayor exactitud significativamente mayor en las interpretaciones terapéuticas, mejor alianza terapéutica en el nivel de intención (trend level), pero un número casi idéntico de cambios cognitivos. Los resultados de este estudio SE y los estudios pasados de CBT sugieren que las ganancias súbitas en los diferentes tratamientos pueden estar asociadas con diferentes mecanismos: cambios cognitivos en CBT e interpretaciones exactas y posiblemente alianza terapéutica en SE.

Resumo

O mecanismo de ganhos súbitos na terapia de suporte expressivo para a depressão

Um ganho súbito é uma grande melhoria sintomática no intervalo de uma sessão. Estudos de terapia cognitivo-comportamental (TCC) relataram que muitas mais mudanças cognitivas aconteceram em sessões pré-ganhos (sessões que precedem imediatamente ganhos súbitos) do que em sessões controlo. Este estudo investiga os ganhos súbitos na terapia de suporte expressiva (SE) para a depressão. Comparando com sessões controle, nas sessões SE pré-ganho, os autores encontraram significativamente maior exactidão interpretativa pelo terapeuta, melhor aliança terapêutica a nível tendencial, mas um número quase idêntico de mudanças cognitivas. Os resultados deste estudo de SE e estudos de CBT anteriores sugerem que os ganhos súbitos em diferentes tratamentos podem estar associados a diferentes mecanismos e factores: mudanças cognitivas na CBT e interpretações exactas e, possivelmente, a aliança terapêutica na SE.

Sommario

I meccanismi di un progresso improvviso nella terapia SE per la depressione

Un progresso improvviso tra una seduta di intervallo è un sintomo di grande miglioramento. Studi di terapia cognitivo-comportamentale (CBT) segnalano che molti altri cambiamenti si presentano nelle sedute precedenti (ovvero nelle sedute immediatamente prima di un progresso improvviso) piuttosto che nelle sedute di controllo. Questo studio indaga progressi improvvisi nella terapia SE (supportive/expressive therapy) per la depressione. In confronto alle sedute di controllo, in quelle di SE (supportive/expressive therapy) gli autori hanno trovato nelle sedute precedenti accuratezza d'interpretazione del terapista significativamente più grandi , un andamento migliore dell'alleanza terapeutica, ma un numero quasi identico dei cambiamenti cognitivi. I risultati di questo studio della terapia SE e passati studi della CBT suggeriscono che i progressi improvvisi nei differenti trattamenti possono essere associati con fattori differenti: nella CBT con i cambiamenti cognitivi e nella SE nell'accuratezza delle interpretazioni e nell'alleanza terapeutica .

Abstract