Suitability for psychoanalytic psychotherapy: a review

OBJECTIVE: To review empirical studies on outpatients' pretherapy suitability for psychoanalytic psychotherapy. METHOD: A literature search for studies in English was made in the databases MEDLINE, PsychInfo and EM-base. Forty-one studies spanning 20 years were selected for a thorough evaluation. RESULTS: Seventy-five per cent of the studies concerned brief dynamic psychotherapy. In general, application of single measures of suitability had a modest predictive value with correlations in the range of 0.17-0.73. There was no consistent difference between various formats of therapies. Most promising variables with the highest correlations with good outcome were: 'good quality of object relations', 'psychological mindedness' and 'motivation for change'. Some clinical guidelines can be drawn from quantitative research to provide the therapist with best method and format. CONCLUSION: The importance of psychological variables known from the development of the brief dynamic therapies and earlier research was confirmed. Most correlations were modest and single factors could not be identified. Multivariate designs that combine different methods and formats with patient characteristics seem most promising in future predictor-outcome research.     

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.     

Suitability for psychoanalytic psychotherapy: validation of the Dynamic Assessment Interview (DAI)

OBJECTIVE: To examine the predictive validity of a particular interview and rating scale of patient suitability for psychoanalytic psychotherapy: The Dynamic Assessment Interview (DAI) scale. METHOD: Seventy-four psychiatric out-patients were interviewed with the DAI and the associations between DAI-scores and measures of outcome and of therapeutic alliance were investigated. RESULTS: Small to moderate correlations were found between the DAI suitability score and outcome (0.06-0.46) and between DAI suitability score and early rated alliance (0.14-0.45). The predictive value of the DAI-score was limited although on a par with the alliance measures used in the study. No other pretherapy predictor variable investigated was found significantly to predict outcome. CONCLUSION: The predictive power of the DAI measure was limited, a result, which is in agreement with results from former studies on suitability.     

Changes in Object Relations in Long-Term Mentally Ill Patients Treated in a Psychiatric Day-Care Unit

Abstract

This naturalistic longitudinal study analyzed the reciprocal dependency of the helping alliance and symptom outcome over the course of mid- and long-term outpatient psychotherapy as practiced in routine care in Germany. Patient-rated helping alliance and symptom distress were assessed repeatedly over a 2-year period in a sample of 259 outpatients in psychodynamic, cognitive–behavioral, and psychoanalytic psychotherapy. Hierarchical linear models showed that initial symptom distress negatively predicted subsequent quality of the helping alliance but not vice versa. Only initial symptom distress affected symptom status at the last treatment session. These results raise doubts about the helping alliance being a strong predictor of outcome and indicate that other patient and therapist variables might be more important for treatment success.     

Prädiktoren für die Inanspruchnahme einer Psychotherapie

BACKGROUND: The aim of this study was to discover prognostic criteria for outpatients' making use of psychotherapy. Data from patients and therapists were collected. SUBJECTS AND METHODS: After initial psychoanalytic interviews, 92 patients at a university psychotherapy outpatient department were asked to complete narrative forms and standardized questionnaires (FMP) regarding their motivation to seek psychotherapy. In addition, the therapists contributed a Global Assessment of Functioning (GAF) and estimate of the initial therapeutic working alliance (iTAB) for each patient. In the follow-up, we investigated patients' actual use of psychotherapy. RESULTS: Sociodemographic variables, personality variables, and diagnoses had only minor prognostic relevance, whereas therapists' assessments of patient resources for therapeutic relationship and work proved to be of high predictive value. CONCLUSION: Positive assessment of a patient's ability for therapeutic working alliance in the initial diagnostic interview is shown to be an important prognostic factor of a patient's entering psychotherapy.     

Clinician interventions related to alliance during the initial interview and psychological assessment

The present review is a comprehensive examination of therapist interventions and characteristics that have been found to positively influence the therapeutic alliance during the psychological assessment or initial interview. A major purpose of this review is to link empirically defined interventions found in the research literature to applied clinical practice so that clinicians from a broad range of perspectives can use these techniques to potentially improve their working relationships with clients during the assessment process. Specific therapist activities and attitudes highlighted by contemporary psychotherapy research are discussed and summarized. A general outline for organizing a pretherapy assessment based on the findings of this review is also provided. In addition, the research reviewed provides no compelling evidence to suggest that different practitioners should conduct the assessment and psychotherapy. Finally, there is some limited evidence to suggest that training initiatives may be helpful with regard to increasing a therapist's abilities to strengthen the alliance, and further research in this area is warranted. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

The relationship among patient contemplation, early alliance, and continuation in psychotherapy

The present study examined the relationship among contemplation stage of readiness to change, formation of an early therapeutic alliance, and psychological distress following the first session of psychotherapy. Significant correlations between the contemplation scores and the therapeutic alliance were found for patients in the contemplation stage. Although contemplation scores were not a factor in return for a second session of psychotherapy, the bond subscale of the alliance inventory did significantly contribute to whether patients returned for therapy. Patient psychological distress was not a significant factor in predicting the early alliance. Results indicate a need for further focus on contemplation with its inherent ambivalence, its relationship to alliance, and continuation in early psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Psychoanalysis and child and adolescent psychiatry.

This report describes psychoanalytic advances in theory and practice as well as changes in knowledge about determinants of behavior from infancy through adolescence. These changes influence how dynamic psychotherapy is conducted. Mother-infant research, affect development, object relations separation-individuation theory, and newer concepts of regulation of self-esteem are explored as they affect treatment strategies. The authors also review countertransference transference and psychoanalytic reconstruing of adolescence as a stage and their influence on how therapy is conducted. Finally, the authors propose using a dynamic formulation as a means of determining where or when the therapist intervenes.     

What a man wants: the male perspective on therapeutic alliance formation

Although the link between client ratings of therapeutic alliance quality and psychotherapy outcome has been well established by previous research, there is still much to be done to clarify what variables are important to clients, particularly men, in the formation of an alliance. Thirty-seven male clients currently undergoing psychotherapy categorized 74 critical incidents for alliance formation in an open-ended manner on the basis of self-perceived relatedness. Multivariate concept-mapping statistical techniques were used to identify the typical way in which the participants conceptualized variables that are important to alliance formation. Nine categories of variables were identified (Bringing out the Issues, Nonverbal Psychotherapist Actions, Emotional Support, Formal Respect, Practical Help, Office Environment, Information, Client Responsibility, and Choice of Professional). Bringing out the Issues emerged as the highest rated and most consistently understood category across the men in this study. The results of this study add to a small but growing body of research on the client's perspective of alliance formation and provide an initial conceptual model of how men understand the variables of common alliance formation. The developed model also provides several hypotheses, which are presented for verification in future research and clinical practice.     

Relational Turn and Psychotherapy Research

Psychoanalytic authors have traditionally been skeptical of nomothetic studies, in which group averages obscure the uniqueness of individual cases. Several relational psychoanalytic authors have expressed more pronounced skepticism, affirming, for example, that given the uniqueness of each therapist-patient dyad, systematic empirical research is particularly problematic. In this article we highlight the potential synergy between relational thinking and today's psychotherapy research, by exploring some of the ways in which the work of relational authors has influenced relational psychotherapy research, shifting the focus of study from validation of the models of treatment to the study of the clinical variables such as: countertransference, therapist empathy, self-disclosure, rupture and resolution in therapeutic alliance, intersubjective negotiation, and the patient-therapist attachment relationship. In conclusion, the aim of this article is to facilitate the dialogue between relational psychoanalysis and the field of psychotherapy research, by exploring ways in which these two different worlds can reciprocally stimulate and enrich one another.     

The role of the idealizing transference in the treatment of psychotic patients

A segment of the psychotherapy with a schizophrenic woman and her psychological testing are presented in this paper. The authors focus on the role of the idealizing transference, and illustrate how its operation, along with the mechanisms of fusion, basic trust, and narcissistic alliance, facilitates the process of therapeutically transforming this patient's object representations. Changes in her hallucinations and delusions reflected this process. The idealizing transference may be more generally applicable in the treatment of individuals with schizophrenic psychosis than was previously thought. Its importance lies in catalyzing changes in patient object representations, object relations, and psychotic symptoms.     

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.     

Fehlleistungen als Empathie-Chance – die Gegenläufigkeit von „Projekten“ der Patientin und der Therapeutin

A patient in a session of behavior therapy commits a Freudian parapraxis relevant for what follows in the session. This is taken as a starting point for a single case conversation analysis (CA). CA is a well known tool in psychotherapy process research. The role of theory as “sensitizing concept” is discussed as relevant for what we see how the therapist responds to the parapraxis. As psychoanalytic authors we got support in our view by Eva-Lotta Brakemeier, full professor for cognitive behavioral therapy at Psychologische Hochschule (PHB), Berlin. Questions of professional integration vs. difference between behavioral therapy and psychoanalysis can be discussed more fertile along such concrete examples.     

The relation between outcome expectation,therapeutic alliance,and outcome among depressed patients in group cognitive-behavioral therapy

Objective: Although patients’ expectation for improvement correlates with their treatment outcome, there remains limited information regarding the mechanisms through which outcome expectation influences outcome. Although several studies have revealed alliance as a mediator of the expectancy-outcome relation, most have focused on individual psychotherapy only. More research is needed examining mediators, including alliance quality, of the outcome expectation-outcome relation in group therapy. Method: This study focused on such associative chains among 91 depressed outpatients who completed 10 weeks of group cognitive-behavioral therapy. We conducted simple and multiple mediation analyses, accounting for the nested data structure. Results: As predicted, we found: (i) The relations between baseline outcome expectation and both posttreatment anxiety and depression were mediated by alliance quality; (ii) the early therapy outcome expectation-posttreatment anxiety relation was mediated by mid-treatment alliance; (iii) the relation between early alliance and posttreatment interpersonal problems was mediated by during-therapy outcome expectation; and (iv) the relation between baseline outcome expectation and posttreatment interpersonal problems was mediated by two variables acting in turn, early alliance and during-therapy outcome expectation. All other tested models were not significant. Conclusions: Results suggest that bidirectional relations between outcome expectation and alliance, with both directions influencing outcome. Clinical and empirical implications are discussed.     

Patient-Therapist Perspective of the Working Alliance in Psychotherapy

This study aimed to examine perceptions of the working alliance in a sample of Spanish patients and therapists. The alliance was measured after the third and tenth psychotherapy sessions using patient and therapist versions of the Spanish adaptation of the Working Alliance Inventory (WAI). After both sessions, correlations between the patients’ and therapists’ ratings, both of total alliance and of the various dimensions of the alliance, were moderate at best. Moreover, after the third psychotherapy session, patients’ scores for the total alliance and the Goal and Task subscales were significantly higher than the scores from their therapists in these dimensions. Following the tenth session, patient ratings exceeded those of their therapists only on the Task subscale. Finally, in contrast to the ratings of patients, therapists’ alliance ratings increased significantly between the third and tenth sessions of psychotherapy. Certain recommendations are presented to improve the study of patient and therapist perceptions of the working alliance and to increase the convergence between them with regard to this central treatment variable.     

How a return to theory could help alliance research

This report aims to clarify alliance theory and extend its role in psychotherapy research. Bordin's (1979) alliance theory concerns the nature and quality of participants' collaborative, purposive work. Alliance is actualized in therapist techniques, client participation, and the dyad's relational features. Alliance is a property of all components of therapy, a concept superordinate to these components and not a component itself. Viewing technique and alliance as equivalent components of therapy confuses 2 levels of thinking, as does conflating alliance with the overall therapy relationship. Examples from contemporary research reports illustrate these points. The logic of alliance measures is clarified, as are the limits of measures' ability to capture key features of collaborative work. This approach opens new avenues for alliance research. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Subjective and intersubjective analyses of the therapeutic alliance in a brief relational therapy

The aim of the study described in this paper was to develop a method for measuring the therapeutic alliance from an intersubjective perspective and to evaluate the efficacy of the measure in predicting psychotherapy outcome. We conducted the study using data from 22 patient-therapist dyads engaged in a 30-session protocol of a brief relational therapy. The alliance measure chosen for this purpose was the short form of the Working Alliance Inventory. We used the subjective patient and therapist versions of the measure and created a correlation index representing the intersubjective congruence between patients and therapists on their ratings of the alliance. We examined the relations among the measures, as well as their predictive relation to an outcome measure. The results showed significant intercorrelations among the three alliance measures, suggesting that all captured aspects of the therapeutic alliance. In addition, all three measures were significantly predictive of outcome, with the correlation index appearing more powerful.     

Alliance in individual psychotherapy

This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as "alliance," "therapeutic alliance," "helping alliance," or "working alliance" were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and non independence of outcome measures) was r = .275 (k = 190); the 95% confidence interval for this value was .25-.30. The statistical probability associated with the aggregated relation between alliance and outcome is p < .0001. The data collected for this meta-analysis were quite variable (heterogeneous). Potential variables such as assessment perspectives (client, therapist, observer), publication source, types of assessment methods and time of assessment were explored.