Psychoanalytic Therapy Research: A Commentary

Psychoanalysis has had two contending perspectives on how to most effectively enhance its theoretical and clinical knowledge base: the traditional intensive case study method innovated by Freud (dubbed qualitative research) and the later developed formal empirical research in accord with the usual canons of objective, natural science (quantitative research). An article by Irwin Hoffman (2009), arguing that objective empirical research should not be privileged over traditional subjective intensive case study as an avenue to psychoanalytic knowledge increase, has aroused multiple responses, pro and con, by psychoanalytic clinicians and researchers. This article assesses four of those responses.     

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.     

Psychotherapy expertise in Singapore: A qualitative investigation

Abstract

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

Effectiveness of Short-Term Psychodynamic Psychotherapy in Preadolescents and Adolescents Affected by Psychiatric Disorders

ObjectiveFew studies have explored the effectiveness of short-term psychodynamic psychotherapy in children and adolescents. We aimed to investigate its efficacy in a heterogeneous group of young patients. We also wanted to check any relation between the improvement and patients’ age, sex, or diagnostic category. MethodsWe recruited a group of 123 patients (11 to 19 years old) with a diagnosis of psychiatric disorders confirmed by Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS). All participants received eight sessions of psychodynamic psychotherapy (“Brief Individuation Psychotherapy” by Senise). They were assessed using the Clinical Global Impression (Severity at baseline, Improvement after treatment), and the Children’s Global Assessment Scale (C-GAS). ResultsWe found a clinically meaningful improvement in most patients (CGI-I 3 or lower; 79 out of 123, 64.2%) and a statistically significant improvement in the overall functioning (as measured by the C-GAS; p<0.001). We found no effect of age or sex of the patient on results obtained; patients with an externalizing disorder had significantly poorer results. ConclusionOur study, although lacking a control group, supports the possibility to use short-term psychodynamic psychotherapy in the treatment of psychiatric disorders in preadolescents and adolescents affected by psychiatric disorders.     

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

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

Learning from Well-Trained and Experienced Dynamic Psychotherapists: Research on the Efficacy of Dynamic Psychotherapy and Its Mechanisms of Change

Is psychodynamic therapy (PT) an evidence-based practice? What makes PT work? In the present article we shall discuss empirical evidence for these as well as other vital questions. First, we shall examine the existing findings concerning two of the most widespread myths about PT: (1) PT is not an evidence-based therapy; (2) PT is not directed at and, therefore, not effective at alleviating symptoms. Second, we shall examine some of the existing findings regarding what it is that actually enables change in PT. The aim of the article is to provide some access to the knowledge accumulated from numerous studies on PT treatments, conducted by dozens of therapists, with the hope that it will benefit clinicians.     

The Scales of Psychological Capacities: Adaptation to an adolescent population

Abstract

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

Aerobic exercise for adult patients with major depressive disorder in mental health services: A systematic review and meta‐analysis

Although exercise is associated with depression relief, the effects of aerobic exercise (AE) interventions on clinically depressed adult patients have not been clearly supported. The purpose of this meta‐analysis was to examine the antidepressant effects of AE versus nonexercise comparators exclusively for depressed adults (18–65 years) recruited through mental health services with a referral or clinical diagnosis of major depression. Eleven e‐databases and bibliographies of 19 systematic reviews were searched for relevant randomized controlled clinical trials. A random effects meta‐analysis (Hedges’ g criterion) was employed for pooling postintervention scores of depression. Heterogeneity and publication bias were examined. Studies were coded considering characteristics of participants and interventions, outcomes and comparisons made, and study design; accordingly, sensitivity and subgroup analyses were calculated. Across 11 eligible trials (13 comparisons) involving 455 patients, AE was delivered on average for 45 min, at moderate intensity, three times/week, for 9.2 weeks and showed a significantly large overall antidepressant effect (g = –0.79, 95% confidence interval = –1.01, –0.57, P < 0.00) with low and nonstatistically significant heterogeneity (I² = 21%). No publication bias was found. Sensitivity analyses revealed large or moderate to large antidepressant effects for AE (I² ≤ 30%) among trials with lower risk of bias, trials with short‐term interventions (up to 4 weeks), and trials involving individual preferences for exercise. Subgroup analyses revealed comparable effects for AE across various settings and delivery formats, and in both outpatients and inpatients regardless symptom severity. Notwithstanding the small number of trials reviewed, AE emerged as an effective antidepressant intervention.     

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.     

The Psychotherapy Outcome Problem: The Development of the Outcome Stability Index

Objective: Psychotherapy research commonly utilizes clients’ last session score as an indicator of treatment outcome. We examined whether this last session score is consistent with what would be predicted based on clients’ general trajectory in psychological functioning across sessions. We focused on the unstandardized residual variance at the last session, as this represents the degree to which the session score is divergent (or not) from what is predicted from the previous sessions (i.e., Outcome Stability Index; OSI). Method: The sample included 27,958 clients who attended on average 9.41 sessions. Each session, clients completed the Behavioral Health Measure-20 as a measure of psychological functioning. We converted the unstandardized residual variance for clients’ last session score into a Cohen’s d coefficient to aid in interpretation. Results: The mean OSI was 0.07 (SD?=?0.58), suggesting excellent stability in their last session therapy outcome scores. However, approximately 33% of clients demonstrated poor or extremely problematic stability in their last session therapy outcome scores. Clients who demonstrated poor stability were classified as demonstrating reliable deterioration. Conclusions: Researchers may want to consider reporting OSI to assist readers’ understanding of the stability of therapy outcomes.

Clinical or methodological significance of this article: Therapy outcome scores can vary from session to session, which can influence how we understand therapy outcomes that rely on last session scores. Studies examining therapy outcomes could report the Outcome Stability Index to better contextualize the results.     

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.     

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.     

Adolescents in psychodynamic psychotherapy: Changes in internal representations of relationships with parents

Abstract

Obwohl Untersuchungen zur Effektivität der Behandlung traditionellerweise auf Vergleichen der Zeitpunkte vor der Behandlung und nach der Behandlung beruhen, scheint es auch nützlich, die Beziehungen zwischen den Zeitpunkten vor der Sitzung und nach der Sitzung einzuschätzen, um ein besseres Verständnis der Mechanismen der Veränderungen zu erlangen. Diese Untersuchung zielte darauf ab, herauszufinden, ob a) die Symptome von Patienten, die an paranoider Schizophrenie litten, sich unmittelbar nach einer Sitzung im Vergleich zu vorher reduzierten und b) es eine systematische Beziehung zwischen dem Angstniveau der Patienten nach der Sitzung und den psychotischen Symptomen gab. Die Datenerhebung umfasste Einschätzungen vor und nach der Sitzung von acht Patienten in 50 integrativen Psychotherapiesitzungen. Die Einschätzungen der Therapeuten wurden als Kontrolle der Selbsteinschätzungen benutzt. Die Ergebnisse weisen auf wichtige Veränderungen bezüglich der Psychopathologie zwischen den Zeitpunkten vor und nach der Sitzung hin und auf eine systematische Beziehung zwischen dem Angstniveau nach der Sitzung und den psychotischen Symptomen. Dies wird hinsichtlich des Beitrags der Angstreduktion als einem wesentlichen therapeutischen Faktor des benutzten Modells diskutiert.

Bien que les études sur l'effectivité des traitements se basent traditionnellement sur la comparaison entre mesures avant et après traitement, il semble bénéfique d’évaluer la relation entre mesures avant et après une séance au cours de la psychothérapie pour mieux comprendre les mécanismes du changement. Cette recherche vise à investiguer (a) si les symptômes de patients souffrant de schizophrénie de type paranoïde diminuent directement après la fin d'une séance par rapport aux symptômes avant la séance, et (b) si il y a une relation systématique après la séance entre le niveau d'anxiété et les symptômes psychotiques par individu. Les données collectées impliquent des auto-évaluations pré- et post-séance par 8 individus dans 50 séances de psychothérapie intégrative. Les évaluations des thérapeutes ont été utilisées comme contrôle des auto-évaluations. Les résultats montrent des changements importants entre les évaluations pré- et post-séances en psychopathologie et une relation systématique entre le niveau d'anxiété post-séance et les symptômes psychotiques. Les résultats sont discutés en relation avec la contribution au soulagement de l'anxiété comme facteur thérapeutique crucial du modèle appliqué.

Si bien los estudios sobre efectividad del tratamiento se han basado tradicionalmente en comparaciones de mediciones tomadas antes y después del tratamiento, parece conveniente evaluar la relación entre las mediciones pre y postsesión durante la psicoterapia a fin de lograr una mejor comprensión de los mecanismos de cambio. Esta investigación tendió a investigar (a) si los síntomas de individuos que sufren de esquizofrenia paranoide se redujeron inmediatamente después de una sola sesión en comparación con los síntomas de su presesión y (b) si hubo alguna relación sistemática entre los niveles postsesión de la ansiedad del individuo y sus síntomas psicóticos. Los datos incluyeron autoevaluaciones pre y postsesión de ocho individuos en 50 sesiones de psicoterapia integradora. Los puntajes de los terapeutas se usaron como control de las autoevaluaciones. Los resultados indican importantes cambios entre los puntajes de la pre y la postsesión de la psicopatología y una relación sistemática entre los niveles postsesión de la ansiedad y los síntomas psicóticos. Se debaten los hallazgos sobre la contribución del alivio de la ansiedad como un factor terapéutico crucial del modelo aplicado.

Tradicionalmente, os estudos da eficiência dos tratamentos têm-se baseado nas comparaç[otilde]es de avaliaç[otilde]es realizadas antes e após o tratamento, porém parece ser benéfico avaliar a relação entre as avaliaç[otilde]es pré e pós-sess[otilde]es de psicoterapia para adquirir uma melhor compreensão dos mecanismos de mudança. A presente investigação procura investigar: (a) se os sintomas dos sujeitos com esquizofrenia do tipo paranóide diminuiam imediatamente após a conclusão de uma única sessão comparando com os sintomas da pré-sessão e, (b) se existia alguma relação sistemática entre os níveis sintomáticos de ansiedade e psicóticos dos pacientes após a sessão. A recolha de dados envolveu auto-avaliaç[otilde]es pré e pós-sess[otilde]es por parte de oito pacientes em 50 sess[otilde]es de psicoterapia integrativa. Foram usadas as avaliaç[otilde]es dos terapeutas como controlo das auto-avaliaç[otilde]es. Os resultados evidenciaram mudanças entre os registos pré e pós-sessão em termos de psicopatologia e uma relação sistemática entre os níveis sintomáticos de ansiedade e os de psicotismo. Os resultados são discutidos em termos das suas contribuiç[otilde]es que o alívio da ansiedade tem como um factor terapêutico crucial do modelo aplicado.

Sebbene gli studi sull'efficacia dei trattamenti sono tradizionalmente legati alla comparazione delle misure prese prima e dopo il trattamento, sembra favorevole valutare la relazione tra le misure pre- e post- seduta durante la psicoterapia, per ottenere una comprensione migliore dei meccanismi di cambiamento.

Questa ricerca ha mirato ad investigare:

–?se i sintomi dei soggetti che soffrono di schizofrenia paranoide erano ridotti immediatamente dopo la conclusione di una singola seduta, comparati con i sintomi della rispettiva pre-seduta e

–?se c'era qualche relazione sistematica tra i livelli post-seduta dell'ansia e dei sintomi psicotici del soggetto.

La raccolta di dati include auto-valutazioni pre- e post- seduta di 8 soggetti in 50 sedute di psicoterapia integrata. Le valutazioni dei terapeuti sono state usate come controllo delle auto-valutazioni.

I risultati indicano cambiamenti importanti tra le valutazioni psicopatologiche pre- e post- seduta e una relazione sistematica tra i livelli post-seduta di ansia e sintomi psicotici.

I risultati sono discussi in relazione al contributo di rilievo dell'ansia come fattore terapeutico cruciale del modello applicato.

     

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

Abstract

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

Generating nonnegative attitudes among parents of depressed adolescents: The power of empathy,concern, and positive regard

Abstract

Parental negativity is associated with the onset and maintenance of adolescent depression. Reducing parental negativity is a primary focus of family-based treatments for this clinical population. This study examined the association between therapist relationship-facilitating and attachment-oriented interventions and the valence (i.e., positivity–negativity) of parents’ attitudes toward their depressed adolescent in a sample of 13 sessions of attachment-based family therapy. Lag sequential analyses revealed that in good alliance sessions relationship-facilitating interventions, such as empathy and positive regard for the parent, were associated with parents’ nonnegative attitudes toward their adolescent in the five speech turns subsequent to the intervention. Attachment-oriented interventions, such as relational reframes, addressing core relational themes, and highlighting vulnerable emotions, were also intermittently associated with nonnegative parental attitudes in good alliance sessions. No such effects were evident for the comparison interventions. This study represents a first step in the process of testing specific strategies for reducing parental negativity in family therapy.     

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.     

Psychotherapy research in developing countries: The case of Latin America

Abstract

This article describes the state of psychotherapy research in Latin America, a developing region, by means of its scientific production as reflected in international and Latin American publications, as well as through a survey and in-depth interviews with clinicians and researchers from the region. The Latin American publication rate is still low in international journals, which stands in contrast with the high level of publication within the region. The survey reveals an interest in research as well as a limited use of research in clinical practice, while exposing the difficulties of researching and publishing. The in-depth interviews, which cover most of the region, specify Latin America's shortcomings and obstacles to researching, as well as its facilitating factors and comparative advantages. The results are discussed within the framework of the colonizer-colonized relationship, Latin American identity, and the creative integration of developed and developing regions.