Client attachment security predicts alliance in a randomized controlled trial of two psychotherapies for bulimia nervosa

Objective: This study investigated the relation between clients' attachment patterns and the therapeutic alliance in two psychotherapies for bulimia nervosa. Method: Data derive from a randomized clinical trial comparing cognitive-behavioral therapy (CBT) and psychoanalytic psychotherapy (PPT) for bulimia nervosa. Client attachment patterns were assessed with the Adult Attachment Interview. Independent raters scored audiotapes of early, middle, and late therapy sessions for 68 clients (175 sessions) using the Vanderbilt Therapeutic Alliance Scale. Results: Client attachment security was found to be a significant (p = .007) predictor of alliance levels at the three measured time points, with clients higher on attachment security developing stronger alliances with their therapists in both treatments as compared to clients higher on attachment insecurity. No evidence was found to support a hypothesized interaction whereby dismissing clients would develop weaker alliances in PPT and preoccupied clients would develop weaker alliances in CBT. Conclusions: As the first study to examine client attachment and therapeutic alliance using observer-based instruments, this study supports the theoretical assumption that clients with secure attachment patterns are likely to develop stronger alliances with their therapist across different treatment settings.     

Conflict begets conflict: Executive control,mental state vacillations,and the therapeutic alliance in treatment of borderline personality disorder

This study evaluated the psychometric properties of the 4 scales of the Behavioral Health Questionnaire-20 (BHQ-20): Global Mental Health, Well-Being, Symptoms, and Life Functioning. Four samples were used: community adults, college students, college students in counseling, and adults in outpatient psychotherapy. Support was found for internal consistency and 2-week test-retest reliability. For construct validity, the BHQ-20 scales distinguished levels of pathology among the samples and were sensitive to improvement across 3 psychotherapy sessions. Concurrent validity correlations with the scales of established measures were at least moderately high. Higher correlations were also found between the BHQ-20 scales and the nonanalogous scales of the established measures. These results, along with high correlations among the BHQ-20 scales, indicated the presence of 1 primary mental health dimension accounting for the variance. The BHQ-20 was proven to be a generally reliable, valid questionnaire that is distinguished by the efficiency with which it assesses mental health.     

Accuracy of therapist perceptions of patients' alliance: Exploring the divergence

Abstract

Objective: The therapeutic alliance is a well-established predictor of psychotherapy outcome, yet much research has shown that therapists' and patients' views of the alliance can diverge substantially. Therapists systematically underestimate their patients' perceived level of alliance, and the correlation between therapist and patient estimates of patient alliance is only moderate. The present study explored the divergence between therapists' and patients' perspectives on patients' alliance experience, and its relations to therapists' concurrent work involvement and session process experiences. Method: Data from 98 patients treated by 26 therapists with psychodynamic psychotherapy were analyzed. Results: Therapist-patient divergence was significantly related to therapists' case-wise work involvement, but not to therapist's views of session process. The best predictor of therapist-patient divergence was therapists experiencing a “distressed practice” work involvement pattern. Conclusion: Although therapists' work involvement experiences are not commonly investigated, they can be a relevant predictor of therapy processes.     

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.     

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.     

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.     

Psychotherapy credibility ratings: Patient predictors of credibility and the relation of credibility to therapy outcome

Abstract

Objective: The current investigation examined the relation between credibility ratings for adult psychotherapies and a variety of patient factors as well as the relation between credibility ratings and subsequent symptom change. Method: A pooled study database that included studies evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders was used. For all studies, a three-item credibility scale was administered at session 2. Patient variables at baseline were used to predict early treatment credibility. Results: Early symptom improvement, age, education, and expectation of improvement were all significantly predictive of credibility scores at session 2. In one combined multiple regression model controlling for treatment, study, and early symptom change, age, education, and expectation of improvement remained significantly predictive of credibility scores. Credibility was predictive of subsequent symptom change even when controlling for age, education, expectation of improvement, and early symptom improvement. Conclusions: These findings suggest that age and education, in addition to expectations of improvement and the amount of early symptom improvement, may influence the patient's perceptions of the credibility of a treatment rationale early in the treatment process and that credibility ratings predict subsequent symptom change.     

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.     

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

     

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.     

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.     

Juggling thoughts and feelings: How do female patients with borderline symptomology and substance use disorder experience change in mentalization-based treatment?

Objective: The aim of this study was to explore the experience of central psychological change processes for female patients with borderline symptomology and substance use disorder in mentalization-based treatment. Method: Semi-structured qualitative interviews on experiences from mentalization-based treatment with 13 participants were conducted. The interview material was analysed within a hermeneutical–phenomenological epistemology, with emphasis on researcher reflexivity. Results: The following themes regarding central psychological change processes were found: “by feeling the feeling,” “by thinking things through,” “by walking in your shoes to see myself” and “by stepping outside of own bad feelings in seeing you.” Two of these themes dealt with intra-psychic modes of how to relate to own mind-states. First, they had a shift from avoiding emotions into tolerating emotions. Second, they discovered the ability to think mental states through. Two themes dealt with mental stances for dealing with interpersonal situations, where one mode included a self-reflective stance in difficult encounters, and the other mode entailed an empathic reflective stance by exploring others’ intentionality. Conclusions: The findings are in line with theoretical assumptions that increasing mentalizing capacity is a central change process for these patients. Furthermore, the findings demonstrate the complex interaction between different modes of mentalizing.

Clinical or methodological significance of this article: The article explores change processes in manualized psychotherapy for patients with comorbid borderline personality disorder and substance use disorder, a focus which is not researched in the clinical literature. We claim that putting attention to this patient group and investigating their potential in psychotherapy is of clinical significance. Methodologically, this article utilizes thematic analyses within an epistemology following a specific procedure that is step based and transparent, thus it is of interest for qualitative researchers who also utilize thematic analyses.     

From symptom relief to interpersonal change: Treatment outcome and effectiveness in inpatient psychotherapy

Abstract

This study evaluated the impact of psychodynamic inpatient psychotherapy on patients’ psychological distress and interpersonal problems during the course of treatment and 1 year later. A total of 156 patients were assessed with the Symptom Checklist-90-Revised and the Inventory of Interpersonal Problems at intake, 4 weeks later, and at the end of therapy. The follow-up assessment was conducted 1 year later. Results support psychodynamic approaches as well as the phase model, which stresses that the goals to be achieved by psychotherapeutic interventions are not only improvement of well-being and symptoms but also changes in interpersonal behavior. Consequently, on a long-term basis, the first 4 weeks of therapy seem to be insufficient, especially for adequate changes on the interpersonal level.     

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.     

Mentalization-based therapy adherence and competence stimulates in-session mentalization in psychotherapy for borderline personality disorder with co-morbid substance dependence

Objective: To test whether adherence to mentalization-based treatment (MBT) principles predict better patient in-session mentalizing. Methods: Two sessions for each of 15 patients with borderline personality disorder and comorbid substance abuse disorder were rated for MBT adherence and competence. Individual patient statements were rated for Reflective Functioning (RF), therapist statements were rated as demanding RF or not. Data were analysed using multilevel modelling. Results: MBT adherence and competence predicted higher session RF (β?=?.58–.75), even while controlling for pre-treatment RF. In addition, therapist interventions directed toward exploring mental states predicted higher RF of subsequent patient responses (β?=?.11–.12). Conclusions: MBT adherence and competence were significantly related to patient in-session mentalizing, supporting the validity of MBT principles. Results point to the importance of supervision for therapists to become adherent to MBT principles. The small number of patients and sessions limits generalizability of results.     

Impact of confrontations by therapists on impairment and utilization of the therapeutic alliance

Objective: Striking the balance between creating challenge through confrontation (drawing attention to discrepancies) to encourage change and offering support through the therapeutic relationship to ensure safety for patients represents a central issue for psychotherapists. The aim of the present study was to assess immediate effects of confrontations by therapists on the therapeutic alliance. Method: We rated video recordings of 77 therapies to measure incidences of alliance ruptures/resolution attempts as well as confrontations by therapists. Change in the therapeutic alliance and therapy outcome were measured through questionnaires filled out by patients. Results: Confrontations were significantly associated with ruptures/resolution attempts on the micro level. Changes in the therapeutic alliance moderated the association between confrontations and alliance ruptures on the macro level: The bigger the fraction of a session containing confrontations, the larger the fraction containing ruptures, given a prior positive change in the therapeutic alliance. Therapists’ use of confrontation during a resolution attempt was associated with significantly better therapy outcomes than no use of confrontation during or no resolution attempt. Conclusions: Confrontations by therapists may temporarily impair the therapeutic alliance, but might also lead to better therapy outcomes when used to make an alliance rupture explicit as part of a resolution attempt.

Clinical or methodological significance: This study provides quantitative explorations of therapists’ fears and hopes regarding the use of confrontations (defined as focus on a discrepancy by the therapist). Results point to associations between confrontations and alliance ruptures, especially in the context of a secure alliance. Furthermore, resolution attempts might profit from initial confrontations regarding the relevant alliance rupture.     

Development and initial validity of the Object Relations Rating Scale

Abstract

The aim of this study was to report on the development and the initial validation of the Object Relations Rating Scale (ORRS), which is a measure of in-session enactments of object relations that draws on a psychodynamic conceptualization of personality organization. Forty participants were included in the study, distributed among neurotic, borderline and psychotic personality organizations (PO). Results showed that the interrater reliability of this new measure is good. Two tests of criterion validity support the validity of the measure: the ORRS discriminates well between the three PO groups and it correlates in expected ways with five PO dimensions. Finally, ORRS scales that pertain to the degree of in-session object relation enactments correlated with a measure of transference intensity (convergent validity), and correlations with therapists experience were low as expected (discriminant validity).     

Instability and discontinuous change in the experience of therapeutic interaction: An extended single-case study of psychodynamic therapy processes

Abstract

The authors developed a concept that applies self-organization theory to psychodynamic principles. According to this concept, episodes of temporary destabilization represent a precondition for abrupt changes within the therapeutic process. The authors examined six courses of therapy (patients diagnosed with depression and personality disorder). After each therapy session, patients rated their experience of the therapeutic interaction. A measure of instability was used to identify episodes of destabilization with respect to patients' interaction experience throughout the process. Episodes of pronounced destabilization occurred in the four courses of therapy that showed better therapy outcomes. These episodes were characterized by temporary strong deteriorations in interaction experience (negative peaks). Three of the four courses showed subsequent discontinuous improvements to a higher level of interaction. Results indicate that the systematic inclusion of a measure of instability is worthwhile in investigations of discontinuous changes. This method allows the theoretical assumptions of the psychodynamic approach to be tested.     

Testing a mediation model of psychotherapy process and outcome in psychodynamic psychotherapy: Previous client distress,psychodynamic techniques,dyadic working alliance,and current client distress

To test a sequential model of psychotherapy process and outcome, we included previous client distress, therapist psychodynamic techniques, dyadic working alliance, and current client distress. For 114 sets of eight-session segments in 40 cases of psychodynamic psychotherapy, clients completed the Outcome Questionnaire-45 and Inventory of Interpersonal Problems-32 after the first and final session, judges reliably coded one middle sessions on the Psychodynamic subscale of the Multitheoretical List of Therapeutic Interventions, and clients and therapists completed the Working Alliance Inventory after every session. Results indicated that higher use of psychodynamic techniques was associated with higher levels of the working alliance, which in turn was associated decreased client distress; and working alliance was higher later in psychotherapy. There was a significant indirect effect of psychodynamic techniques on decreases in distress mediated by the working alliance. Implications for theory, practice, and research are provided.

Clinical or methodological significance of this article: Conducted a longitudinal, latent variable examination of the relationships of psychodynamic techniques and working alliance on client distress. Psychodynamic techniques have an indirect effect on decreases in client distress through the dyadic working alliance.     

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.