Transference interpretations in short-term dynamic psychotherapy.

Transference interpretations are one of the distinguishing features of dynamically oriented psychotherapy. Previous studies have suggested that too many transference interpretations may be detrimental, in particular for certain kinds of patients. Given the potential for negative effects, attempts to validate (replicate) the previous findings are worthwhile. The relationships between the frequency and proportion of transference interpretations and both the therapeutic alliance and treatment outcome were examined in a sample of 40 patients who received time-limited, 20-session, individual psychotherapy. Inverse relationships were found between the frequency of transference interpretations and both patient-rated therapeutic alliance and favorable outcome. The relationships differed as a function of the patient personality characteristic known as quality of object relations (QOR). These results extend previous findings regarding transference technique in short-term dynamic therapy with low-QOR and high-QOR patients.     

Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome

The purpose of the study was to compare an interview measure of quality of object relations to questionnaire and interview measures of recent interpersonal functioning with respect to the prediction of therapeutic alliance and psychotherapy outcome. The sample consisted of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical-trial investigation. Ratings of therapeutic alliance were provided independently by the patient and the therapist after each session. Outcome measures, which were provided by three sources (patient, therapist, and independent assessor), covered the areas of interpersonal functioning, psychiatric symptomatology, self-esteem, and life satisfaction. Quality of object relations, which characterizes the patient's lifelong pattern of relationships, was the best predictor. It was significantly related to patient-rated and therapist-rated therapeutic alliance and to patient improvement of both general symptomatology and specific target problems. The study also replicated previous studies that have reported significant relationships between therapeutic alliance and therapy outcome. The advantages of pretherapy predictors of therapy outcome, such as quality of object relations, 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.     

Analysis of the patient-therapist relationship in dynamic psychotherapy: an experimental study of transference interpretations

OBJECTIVE: The purpose of this study was to measure the effects of transference interpretations (the assumed core active ingredient) in dynamic psychotherapy, using an experimental design. METHOD: One hundred patients were randomly assigned to two groups. One group received dynamic psychotherapy over 1 year, with a moderate level of transference interpretations, while the other group received dynamic psychotherapy with no transference interpretations. The most common axis I disorders were depression and anxiety disorders. Forty-six patients fulfilled the general criteria for personality disorder. Seven experienced psychotherapists treated patients in both groups. Five full sessions from each treatment were rated by two evaluators with process measures in order to document treatment integrity. Outcome variables were the Psychodynamic Functioning Scales, Inventory of Interpersonal Problems Scale-Circumplex version, Global Assessment of Functioning Scale, and Symptom Checklist-90-R. Quality of Object Relations Scale (lifelong pattern) and personality disorders were preselected as possible moderators of treatment effects. Change was assessed using linear-mixed models. Clinically significant change was also calculated. RESULTS: The authors could not demonstrate differential treatment effects between the groups. However, the moderator analyses showed that transference interpretations were more helpful for patients with a lifelong history of less mature object relations. Small negative effects were observed for patients with mature object relations. CONCLUSIONS: The authors could not show differences in average effectiveness between treatments. However, the moderator analyses indicated that treatment worked through different active ingredients for different patients. Contrary to common expectation, patients with poor object relations profited more from therapy with transference interpretations than from therapy with no transference interpretations.     

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.     

Negative Indicators,Therapeutic Alliance,and Therapy Outcome

The present study measured the relationship among negative psychotherapy process indicators, therapeutic alliance, and outcome. A sample of 40 patients at a university psychological clinic were administered pre- and posttreatment questionnaires, and three excerpts from audiotaped sessions were rated for level of alliance and negative indicators. Results showed negative indicators and lower therapeutic alliance were significantly related, more so in long therapies (greater than 40 sessions). There was a significant relationship between negative indicators and outcome as rated by participants, but the relationship to symptomatic improvement was much weaker, appearing in the longlength group only. Pretreatment symptomatology was significantly related to some negative indicators in the medium-length group (20–40 sessions). The strong correlations between alliance and negative indicators suggest they may be tapping aspects of one underlying construct, the state of the therapist-patient relationship.     

When Is Transference Work Useful in Psychodynamic Psychotherapy? Main Results of the First Experimental Study of Transference Work (FEST)

This article presents the main results of the First Experimental Study of Transference (FEST). The background of the study, as well as the aims, main hypotheses, and methods are described. The participants were 100 patients who were randomized to psychodynamic psychotherapy of one year's duration, with transference work or without transference work. The analyses of the effects of psychodynamic psychotherapy with transference work versus psychodynamic psychotherapy without transference work are presented. The two treatments were equally effective, but analyses of moderators revealed differential effects. Patients with low quality of object relations (QOR) and/or presence of personality disorder showed specific positive effects of transference work. Female patients responded better than men. Further analyses included mechanisms of change and three-way interactions among factors, with an impact on outcome. We also found that (1) insight was a mediator of change, and (2) that the specific effects of transference work were influenced by interaction of object relations and alliance, but in the direct opposite direction of what is generally maintained in mainstream clinical theory. For patients with more mature object relations and high alliance, a negative effect of transference work was observed.     

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.     

Modereferater

Background: Gender as a moderator of long-term treatment effects has to a very little extent been explored in individual psychotherapy. We have previously reported a short-term difference in treatment-response to transference interpretations between women with poor relational functioning (low Quality of Object Relations Scale; low QOR) and men with good relational functioning (high QOR). The present study focuses on whether there also is a sustained difference in treatment-response between those two subgroups. Material and method: In the First Experimental Study of Transference-interpretations (FEST), patients (n=100) were randomized to receive dynamic psychotherapy over 1?year with either a moderate level of transference interpretations or no transference interpretations. Assessments were made at pre-treatment, mid-treatment, post-treatment, and at 1- and 3-year follow-ups. The outcome measures used were the Psychodynamic Functioning Scales (PFS), Inventory of Interpersonal Problems (IIP-C), Global Assessment of Functioning (GAF) and Symptom Checklist-90 (GSI). Change was assessed using linear–mixed models. Results: In the moderator analyses, women with low QOR showed a significant positive long-term treatment effect of transference interpretation (P=0.005), while men with high QOR responded equally well to both therapies. Conclusion: Women with poor relational functioning and men with good relational functioning showed sustained different treatment-response to transference interpretations.     

Transference, transference interpretations, and transference-focused psychotherapies

The concept of transference and the use of transference interpretations in psychotherapy have been highly controversial topics garnering frequent attention both within psychoanalysis and across multiple orientations of psychotherapy. In this article, we review the empirical evidence as it bears on this controversy and discuss the implications of the evidence for psychoanalysis, psychodynamic psychotherapy, and therapy in general. We provide a brief historical and contextual overview, followed by a discussion of the development of the concept of transference. We then discuss the evidence for the concept of transference from basic psychological research and contend that these findings are not only consistent with a social-cognitive and information processing model, but that they may also indicate conflict and defensive processes suggestive of a dynamic transference process model. We continue with a discussion of the evidence for the concept of transference from psychotherapy research and examine process findings relating to the use of transference interpretations and transference-focused psychotherapies. Finally, we present the implications of this emerging evidence for clinical practice. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Cohesion, alliance and outcome in group psychotherapy

Cohesiveness has been viewed as the group psychotherapy equivalent of the therapeutic alliance in individual treatment. Although researchers have attempted to study the concept of cohesion in group treatment, understanding of this so-called "curative" group factor remains quite primitive. In this study of 12 time-limited psychotherapy groups, with a total of 90 nonpsychotic outpatients, we explore the relationships between cohesion, alliance and treatment outcome. Our cohesion measure is a new instrument, the Harvard Community Health Plan Group Cohesiveness Scale, developed for use with group therapy videotapes. To measure alliance we have modified the Penn Helping Alliance Scale (Group Alliance Scale) to be scored from videotapes of group sessions. Both of these instruments use trained observers to make ratings for the group-as-a-whole. The outcome battery for patients in these groups included a widely varied set of measures, enabling us to view change from a number of perspectives. Our findings indicate that cohesion and alliance as measured here are related concepts. We also find that both cohesion and alliance appear to have strong relationships with improved self-esteem and reduced symptomatology for patients in these groups. In addition, it appears that outcome is most related to cohesion in the first 30 minutes of a group session. Implications of these and other findings are discussed.     

Therapeutic alliance, cohesion and outcome in a long-term analytic group. A preliminary study

We studied the ongoing relationship of patients and their therapist in a long-term, analytic group. The therapeutic alliance was rated weekly and group cohesion was rated every month, by patients and therapist. The patients' symptoms (SCL-90-R) and interpersonal problems (IIP-C) were rated every third month during therapy (self-reports). There was a steady increase in the alliance ratings by patients and therapist during the first 2 years of therapy. This differs from findings in short-term therapies, where the alliance quickly reaches a high level and then remains stable throughout therapy. Therapist ratings of early alliance correlated significantly with positive symptomatic outcome, but did not predict interpersonal change. Patients' alliance ratings did not predict change. Early cohesion ratings did not predict change. The concordance between the patients' and the therapist's alliance ratings was highest between 16 and 30 sessions, and was essentially maintained throughout therapy. An early concordance of patient and therapist alliance ratings predicted a better symptomatic outcome. The measures of therapeutic alliance and cohesion used in this study seem to address different elements in the group process.     

Different perspectives of the therapeutic alliance and therapist technique in 2 forms of dynamically oriented psychotherapy.

OBJECTIVE: This study addresses several issues concerning patients' and therapists' perceptions of key therapy process variables. This includes examining whether patients and therapists differ in their perceptions of the therapeutic alliance and therapist technique, what the relation is between perceptions of the alliance and technique, and whether these perceptions are predictive of treatment outcome. METHOD: Patient and therapist perceptions of the therapy process were provided in a comparative trial of 2 forms of short-term individual dynamic psychotherapy. Patients (n = 144) were randomly assigned to each condition. Treatment outcome was assessed using a large, comprehensive battery of reliable measures. RESULTS: The findings revealed several differences in the patients' and therapists' ratings of the alliance and technique in the 2 forms of therapy. Patient ratings of the alliance and technique were predictive of treatment outcome. CONCLUSION: The findings contribute to understanding the extent to which therapy participants share views of therapy processes and highlight the importance of the therapist's attending to the patient's perception of therapy.     

The Danish national multicenter schizophrenia project: assessment of psychotic patients for dynamic psychotherapy (APPP)

Clinicians need guidance in selecting schizophrenic patients for individual psychodynamic psychotherapy. The purpose of the present study was to investigate whether a 17-item questionnaire (APPP) for quantification of suitability for psychotherapy could predict continuance, adherence and outcome from individual dynamic psychotherapy with patients with schizophrenic psychoses. Therapists rated 72 first-episode patients with schizophrenic psychoses in the initial interview. The scores were then correlated to the course of therapy and change in symptoms. APPP was tested to have good psychometric characteristics and had a satisfactory interrater reliability ((ICC,2)=0.70), when four raters scored eight videotaped interviews with eight different patients. The scale scores were highly correlated to "therapeutic alliance" measured by the Working Alliance Inventory (WAI) and the Active Engagement Scale (AES). APPP suitability gave a good early prediction of adherence to therapy (continued in therapy at least 12 months and a satisfactory number of sessions), but had no predictive value of symptomatic improvement or improved social function after 1 year.     

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.     

Predictive value of object relations for therapeutic alliance and outcome in psychotherapy for depression: an exploratory study

The concept of object relations has been shown to be relevant for the process and outcome of psychodynamic psychotherapies. However, little is known about its relevance for the psychotherapeutic treatment of depression. In this study, we explored the predictive value of object relational functioning (ORF) for the therapeutic alliance and outcome of short-term psychodynamic supportive psychotherapy in patients with mild to moderately severe depression. The ORF of 81 patients was rated by using the Developmental Profile. The overall maturity of ORF measured at baseline was higher in patients who showed a better treatment response. In multiple regression analysis, the adaptive level of individuation appeared to be specifically predictive of outcome. Patients with a recurrent depression showed less mature levels of ORF, lower adaptive levels and a higher score on the symbiotic level. No association was found between ORF and therapeutic alliance during treatment. In contrast to the single measure of alliance early in therapy, the growth of the alliance was related to outcome. The study indicated the relevance of ORF for depression and established that it is distinctive from the actual therapeutic alliance.     

Interaction between alliance and technique in predicting patient outcome during psychodynamic psychotherapy

The current study examined whether alliance interacted with psychodynamic interventions to predict patients' psychotherapy outcomes. A prospective study of psychodynamic psychotherapy with 68 outpatients who were treated by 23 therapists was used. The patients rated the alliance with their therapist early in treatment. Therapist use of psychodynamic techniques was reliably rated by independent clinicians for the same sessions. The therapy outcomes were measured at the end of treatment based on the patients' global symptomatology as well as estimate of improvement across a broad range of functioning. In all models, we controlled for the patients' pretherapy psychiatric severity. Analyses were conducted using multilevel modeling to account for therapist effects. Results revealed that patient rated alliance was significantly related to improvement on a measure of broad band functioning. In addition, alliance and psychodynamic interventions interacted to predict this scale of multidimensional therapy outcome. Further, results showed that several individual psychodynamic techniques interacted with alliance that were meaningfully related to this measure of broad band outcome including (1) linking current feelings or perceptions to the past; (2) focusing attention on similarities among patient's relationships repeated over time, settings, or people; and (3) identifying recurrent patterns in patient's actions, feelings, and experiences. In this sample of outpatient psychodynamic treatments, the dynamic techniques were most effective when provided in the context of strong alliances.     

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.     

Long-term effects of transference interpretation in dynamic psychotherapy of personality disorders

Background

Only a few treatment studies of personality disorders (PD) patients are on longer-term psychotherapy, general outcome measures are used, and follow-up periods are usually short. More studies of long-term therapies, using outcome measures of core psychopathology, are needed.

Method

This study is a dismantling randomized controlled clinical trial, specifically designed to study long-term effects of transference interpretation. Forty-six patients with mainly cluster C personality disorders were randomly assigned to 1 year of dynamic psychotherapy with or without transference interpretations. The outcome measures were remission from PD, improvement in interpersonal functioning, and use of mental health resources in the 3-year period after treatment termination.

Results

After therapy with transference interpretation PD-patients improved significantly more in core psychopathology and interpersonal functioning, the drop-out rate was reduced to zero, and use of health services was reduced to 50%, compared to therapy without this ingredient. Three years after treatment termination, 73% no longer met diagnostic criteria for any PD in the transference group, compared to 44% in the comparison group.

Conclusions

PD-patients with co-morbid disorders improved in both treatment arms in this study. However, transference interpretation improved outcome substantially more. Long-term psychotherapy that includes transference interpretation is an effective treatment for cluster C personality disorders and milder cluster B personality disorders.     

The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive-behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were assessed by patient- and therapist-report after each of the first 6 sessions. Results indicated that lower rupture intensity and higher rupture resolution were associated with better ratings of the alliance and session quality. Lower rupture intensity also predicted good outcome on measures of interpersonal functioning, while higher rupture resolution predicted better retention. Patients reported fewer ruptures than did therapists. In addition, fewer ruptures were reported in cognitive-behavioral therapy than in the other treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved).