The patient-therapist interaction and the recognition of affects during the process of psychodynamic psychotherapy for depression

The perceptions of patients (n = 25) and their therapists about psychodynamic psychotherapy for depression were assessed during the first treatment year using 23 scales. Patients and therapists independently evaluated the impact of depression on the therapeutic experience of the patients. The estimations of the impact of depression by the patients and therapists were concordant in the majority of the subjects, reflecting mutual tuning and a working alliance. The roles of affects and frustrating subjects in the treatment relationship were evaluated as significantly different by the patients and the therapists. The results highlight the importance of working on the expression of affects in the psychotherapy of depression.     

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.     

Intensive Evening Outpatient Treatment for Patients With Personality Dysfunction: Early Group Process,Change in Interpersonal Distress,and Longer-Term Social Functioning

Objective: Entrenched interpersonal difficulties are a defining feature of those with personality dysfunction. Evening treatment—a comprehensive and intensive group-oriented outpatient therapy program—offers a unique approach to delivering mental health services to patients with chronic personality dysfunction. This study assessed change in interpersonal problems as a key outcome, the relevance of such change to future social functioning, and the influence of early group processes on this change. Method: Consecutively admitted patients (N = 75) to a group-oriented evening treatment program were recruited; the majority were diagnosed with personality disorder. Therapy outcome was represented by scores on the Inventory of Interpersonal Problems. Follow-up outcome was represented by the global score of the Social Adjustment Scale. Group climate, group cohesion, and the therapeutic alliance were examined as process variables. Results: Patients experienced substantial reduction in distress associated with interpersonal problems; early process factors that reflected a cohesive and engaged group climate and stronger therapeutic alliance were predictive of this outcome. Improvement in interpersonal distress was predictive of global social functioning six months later. The therapeutic alliance most strongly accounted for change in interpersonal problems at posttreatment and social functioning at follow-up. Conclusions: A comprehensive and integrated outpatient group therapy program, offered in the evening to accommodate patients’ real-life demands, can facilitate considerable improvement in interpersonal problems, which in turn influences later social functioning. The intensity and intimacy of peer interactions in the therapy groups, and a strong alliance with the program therapists, are likely interacting factors that are particularly important to facilitate such change.     

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.     

Suicide Ideation Is Related to Therapeutic Alliance in a Brief Therapy for Attempted Suicide

The objective of this study was to investigate the role of therapeutic alliance on suicide ideation as outcome measure in a brief therapy for patients who attempted suicide. Sixty patients received the 3-session therapy supplemented by follow-up contact through regular letters. Therapeutic alliance was measured with the Helping Alliance Questionnaire (HAQ). Outcome at 6 and 12 months was measured with the Beck Scale for Suicide Ideation (BSS). Therapeutic alliance increased from session 1 to session 3. Higher alliance measures correlated with lower suicidal ideation at 12 months follow-up. A history of previous attempts and depression had a negative affect on therapeutic alliance. The results suggest that in the treatment of suicidal patients therapeutic alliance may be a moderating factor for reducing suicide ideation.     

Transference interpretations, therapeutic alliance, and outcome in short-term individual psychotherapy

Relationships between the proportion of transference interpretations provided by therapists and both therapeutic alliance and therapy outcome were investigated for a sample of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical trial investigation. Inverse relationships were found between the proportion of transference interpretations and both therapeutic alliance and favorable therapy outcome for patients with a history of high quality of object relations. An examination of individual sessions revealed evidence that was consistent with two different, but not mutually exclusive, causal explanations. The first concerned the negative effects of high proportions of transference interpretations; the second concerned the reaction of the therapist to the presence of a weak therapeutic alliance. While the evidence from our study was correlational, it was sufficiently strong to warrant alerting clinicians to the possibility of negative treatment effects when high levels of transference interpretations are used with certain types of patients receiving short-term individual psychotherapy.     

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.     

Predicting the outcome of antidepressants and psychotherapy for depression: a qualitative, systematic review

As treatment outcome in depression varies widely, it is important to understand better the predictive value of particular patient characteristics. However, qualitative systematic reviews of the association between easily identifiable patient characteristics and outcome for commonly used treatment options have been unavailable. This article provides an overview of the consistency of findings on the association between sociodemographic factors and depression characteristics, on the one hand, and outcomes of pharmacotherapy, cognitive-behavioral therapy, and interpersonal/psychodynamic psychotherapy for major depression, on the other. There were no findings indicating that gender was associated with treatment outcome in the case of tricyclic antidepressants. There are some indications that younger patients respond worse to tricyclics, whereas especially women appeared to have better outcomes with modern antidepressants (selective serotonin/norepinephrine reuptake inhibitors). Marital status may be related to better outcome in the case of antidepressants and cognitive-behavioral therapy. Longer duration of depression was identified as a negative predictor, most consistently in psychotherapy. In none of the treatment modalities was recurrence a negative predictor. The relation between severity of depression and outcome appeared to be complex, precluding any straightforward inferences.     

Perceived treatment difficulty and therapeutic alliance on an adolescent psychiatric hospital unit

On an 8-bed adolescent psychiatric unit, 69 patients were rated over the course of more than one year [corrected]. A set of rating scales was used to determine the relationships of treatment and therapeutic alliance difficulties with staff ratings of patient qualities, family issues, and treatment outcome. Findings underscore the clinical relevance of treatment difficulty and therapeutic alliance in conceptualizing the therapeutic action of the hospital treatment.     

Enhanced adaptive capacities after brief treatment for depression

Using data from the National Institute of Mental Health-sponsored Treatment of Depression Collaborative Research Program, the authors examined predictors of the intensity of depressive symptoms after the brief treatment of depression. Multilevel modeling was applied to measures of depression and stress assessed at termination and at 6-, 12-, and 18-month follow-ups. The slope of depression on stress was used to index stress reactivity. Patients with high mean levels of stress experienced more intense depressive symptoms, but this effect was moderated by patients' reports of the extent to which they had acquired enhanced adaptive capacities (EACs) in treatment. Patients who reported high EAC early in the follow-up were more resilient in the face of stress than those with low EAC. Greater EACs were found for patients who received psychotherapy than medication or placebo and, across all treatments, for patients with a stronger therapeutic alliance. These findings suggest that treatments should be evaluated in terms of their impact on patients' developing adaptive capacities as well as the reduction of symptomatology.     

Impact of defense style on brief psychotherapy of postpartum depression

In this study, we evaluated the impact of defense style (DS) on outcome and its relation to the therapeutic alliance. Women with postpartum depression were allocated to a brief psychotherapeutic intervention. To evaluate DS and the therapeutic alliance, the Defense Style Questionnaire and the Working Alliance Inventory were employed. The main outcome was the Edinburgh Postnatal Depression Scale score at end point; anxiety and retention in treatment were also evaluated. Fifty-nine patients were included; 46 completed the therapy and 65.4% responded (Edinburgh Postnatal Depression Scale score <10). Intense use of immature defenses was related to persistence of depression and anxiety symptoms at end point, even when controlled for potential confounders. Results tended to confirm a hierarchy of DSs independently of the alliance. Clinicians should be aware of possible differential responses to brief psychotherapies related to DS.     

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.     

Predictive factors for the outcome of emotional and/or behavioural disorders in 18- to 48-month-old children after parent-child psychotherapy: Protocol of a European prospective cohort study

ObjectivesSeveral studies have shown that in young children, behavioural and/or emotional disorders are more difficult to manage than regulatory disorders. Moreover, data are lacking on outcome predictive factors. This article presents a short synthesis of previous research about outcome predictive factors in child psychiatry. It also describes the protocol of a longitudinal observational European multicentre study the main objective of which was to identify predictive factors of behavioural and emotional disorder outcome in toddlers after parent-child psychotherapy. The secondary objectives were to study predictive factors of the outcome in parents (anxiety/depression symptoms) and parent-child relationship.MethodIn order to highlight medium-effect size, 255 toddlers (age: 18 to 48 months) needed to be included. Outcomes will be assessed by comparing the pre- and post-therapy scores of a battery of questionnaires that assess the child's symptoms, the parents’ anxiety/depression, and the parent-child relationship. Multivariate linear regression analysis will be used to identify predictive factors of the outcome among the studied variables (child age and sex, socio-economic status, life events, disorder type, intensity and duration, social support, parents’ psychopathology, parents’ attachment, parent-child relationships, therapy length and frequency, father's involvement in the therapy, and therapeutic alliance).Expected results and conclusionThis study should allow identifying some of the factors that contribute to the outcome of externalizing and internalizing disorders, and distinguishing between pre-existing and treatment-related variables. It should also help to identify children at higher risk of poor outcome who require special vigilance on the part of the therapist. It should confirm the importance of therapeutic alliance.Trial registrationID-RCB 2008-A01088-47.     

Levels and patterns of the therapeutic alliance in brief psychotherapy

We examined the relevance of the level and pattern of the therapeutic alliance in 44 cases of three different, manualized 30-session treatments using patient ratings of the Working Alliance Inventory after each session. It was hypothesized that both high-alliance level and either a linear increase in alliance rating or a series of brief rupture-and-repair episodes would be found in successful treatments. We also hypothesized that a more global high-low-high pattern predicted in the literature would not be present. Consistent with the literature, higher alliance levels were found to be related to improved outcome. As predicted, we did not find a global, high-low-high pattern. Local rupture-and-repair patterns were found in 50% of the cases; linear trends were found in 66% of the cases. There was no relationship between outcome and either pattern. We found no differences among the treatments.     

Group cognitive behavior therapy for Japanese patients with social anxiety disorder: preliminary outcomes and their predictors

Background

The present study was designed to evaluate the efficacy of an internet-based therapy (Interapy) for Posttraumatic Stress Disorder (PTSD) in a German speaking population. Also, the quality of the online therapeutic relationship, its development and its relevance as potential moderator of the treatment effects was investigated.

Method

Ninety-six patients with posttraumatic stress reactions were allocated at random to ten sessions of Internet-based cognitive behavioural therapy (CBT) conducted over a 5-week period or a waiting list control group. Severity of PTSD was the primary outcome. Secondary outcome variables were depression, anxiety, dissociation and physical health. Follow-up assessments were conducted at the end of treatment and 3 months after treatment.

Results

From baseline to post-treatment assessment, PTSD severity and other psychopathological symptoms were significantly improved for the treatment group (intent-to-treat group × time interaction effect size d = 1.40). Additionally, patients of the treatment condition showed significantly greater reduction of co-morbid depression and anxiety as compared to the waiting list condition. These effects were sustained during the 3-months follow-up period. High ratings of the therapeutic alliance and low drop-out rates indicated that a positive and stable therapeutic relationship could be established online. Significant improvement of the online working alliance in the course of treatment and a substantial correlation between the quality of the online relationship at the end of treatment and treatment outcome emerged.

Conclusion

Interapy proved to be a viable treatment alternative for PTSD with large effect sizes and sustained treatment effects. A stable and positive online therapeutic relationship can be established through the Internet which improved during the treatment process.

Trial registration

Australian Clinical Trials Registry ACTRN012606000401550     

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.     

Predictors of outcome and completion status in cognitive therapy for depression

Abstract

The aim of this study was to investigate the relationship among therapy outcome, premature termination, and client interpersonal style and therapeutic alliance. Of the 94 clients who began cognitive therapy for the treatment of depression, 24 did not complete their agreed-on number of therapy sessions, had poorer outcomes and alliance scores, and were more likely to have an ambivalent interpersonal style. However, mediation of this relationship between interpersonal style and completion status by alliance was not significant. Therapy outcomes for all clients were better for clients with a secure interpersonal style than for those with an insecure interpersonal style, particularly avoidant. The association between interpersonal style and outcome was mediated by the therapeutic alliance.     

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.     

Long-term changes in defense styles with psychodynamic psychotherapy for depressive, anxiety, and personality disorders

OBJECTIVE: This study examined 1) whether patients with chronic and recurrent anxiety and depressive disorders and/or personality disorders demonstrate improvement in their defense styles with long-term dynamic psychotherapy and 2) what the relationship is between defense style change and symptomatic change. METHOD: Measures of defense (Defense Style Questionnaire) and symptoms and functioning were administered at regular intervals over the course of 3-5 years to adults who entered a naturalistic study of long-term psychodynamic psychotherapy. With hierarchical linear regression, the relative contributions of change in variables on the Defense Style Questionnaire to change in other outcome variables were calculated. RESULTS: Those with high initial scores on the maladaptive and self-sacrificing defense styles improved, with effect sizes of 0.80 and 0.67, while overall defensive functioning improved, with an effect size of 0.43. The effect size of the change in score on the Global Assessment of Functioning scale was 0.82. Depressed subjects improved their scores significantly on the Hamilton Depression Rating Scale, and there was a significant improvement in distress, as measured by the SCL-90-R. Changes in score on the Defense Style Questionnaire added substantially to the prediction of variance in these three outcomes above their initial levels. A higher level of defensive functioning also predicted a better self-reported therapeutic alliance. CONCLUSIONS: Defense styles became more adaptive and symptoms improved over time in patients who started with scores in the clinical range. Change in defense style predicts symptomatic change, but causation has not been established.     

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.